Severe sepsis in cirrhosis

Multiresistant bacterial infections in liver cirrhosis: Clinical impact and new empirical antibiotic treatment policies

Recently, important changes have been reported regarding the epidemiology of bacterial infections in liver cirrhosis. There is an emergence of multiresistant bacteria in many European countries and also worldwide, including the United States and South Korea. The classic empirical antibiotic treatment (third-generation cephalosporins, e.g., ceftriaxone, cefotaxime or amoxicillin-clavulanic acid) is still effective in infections acquired in the community, but its failure rate in hospital acquired infections and in some health-care associated infections is high enough to ban its use in these settings. The current editorial focuses on the different epidemiology of bacterial infections in cirrhosis across countries and on its therapeutic implications.

Acute-on-chronic liver failure: a new clinical entity

Patients hospitalized for an acute complication of cirrhosis who also have organ failure(s) are at high risk of short-term death. The term acute-on-chronic liver failure (ACLF) is used to characterize these patients. Until recently, there was no evidence-based definition of ACLF. The results of a large prospective observational European study called Chronic Liver Failure Consortium Acute-on-Chronic Liver Failure in Cirrhosis study were published in 2013 establishing diagnostic criteria for ACLF in a large series of hospitalized patients who had an acute complication of cirrhosis. In addition, this study described the natural history of ACLF. According to the Acute-on-Chronic Liver Failure in Cirrhosis study, ACLF is now considered a new clinical entity because it is distinct from traditional decompensated cirrhosis, based not only on the presence of organ failure(s) and high mortality rate but also on younger age, alcoholic etiology of cirrhosis, higher prevalence of some precipitating events (bacterial infections, active alcoholism), and higher level of systemic inflammation. ACLF is a new entity also because it cannot be explained entirely by severe sepsis or severe alcoholic hepatitis; a large proportion of cases are of unknown origin. ACLF should be considered as a whole that includes subcategories such as severe sepsis, severe alcoholic hepatitis, and others, which have yet to be defined. ACLF is a relatively common syndrome because it occurs in 31% of hospitalized patients with cirrhosis who have an acute complication of their liver disease. In these patients, ACLF is the most common cause of death.

Alcoholic liver disease: mechanisms of injury and targeted treatment

Alcoholic liver disease (ALD) is a complex process that includes a wide spectrum of hepatic lesions, from steatosis to cirrhosis. Cell injury, inflammation, oxidative stress, regeneration and bacterial translocation are key drivers of alcohol-induced liver injury. Alcoholic hepatitis is the most severe form of all the alcohol-induced liver lesions. Animal models of ALD mainly involve mild liver damage (that is, steatosis and moderate inflammation), whereas severe alcoholic hepatitis in humans occurs in the setting of cirrhosis and is associated with severe liver failure. For this reason, translational studies using humans and human samples are crucial for the development of new therapeutic strategies. Although multiple attempts have been made to improve patient outcome, the treatment of alcoholic hepatitis is still based on abstinence from alcohol and brief exposure to corticosteroids. However, nearly 40% of patients with the most severe forms of alcoholic hepatitis will not benefit from treatment. We suggest that future clinical trials need to focus on end points other than mortality. This Review discusses the main pathways associated with the progression of liver disease, as well as potential therapeutic strategies targeting these pathways.

Acute-on-chronic liver failure: A new syndrome that will re-classify cirrhosis

Acute-on-chronic liver failure (ACLF) is a recently recognized syndrome characterized by acute decompensation (AD) of cirrhosis and organ/system failure(s) (organ failure: liver, kidney, brain, coagulation, circulation and/or respiration) and extremely poor survival (28-day mortality rate 30-40%). ACLF occurs in relatively young patients. It is especially frequent in alcoholic- and untreated hepatitis B associated-cirrhosis, in addition it is related to bacterial infections and active alcoholism, although in 40% of cases no precipitating event can be identified. It may develop at any time during the course of the disease in the patient (from compensated to long-standing cirrhosis). The development of ACLF occurs in the setting of a systemic inflammation, the severity of which correlates with the number of organ failures and mortality. Systemic inflammation may cause ACLF through complex mechanisms including an exaggerated inflammatory response and systemic oxidative stress to pathogen- or danger/damage-associated molecular patterns (immunopathology) and/or alteration of tissue homeostasis to inflammation caused either by the pathogen itself or through a dysfunction of tissue tolerance. A scoring system composed of three scores (CLIF-C OFs, CLIF-C AD, and CLIF-C ACLFs) specifically designed for patients with AD, with and without ACLF, allows a step-wise algorithm for a rational indication of therapy. The management of ACLF should be carried out in enhanced or intensive care units. Current therapeutic measures comprise the treatment for associated complications, organ failures support and liver transplantation.

Increased delayed mortality in patients with acute-on-chronic liver failure who have prior decompensation

BACKGROUND AND AIM

Patients with acute-on-chronic liver failure (ACLF) represent a complex population with differential prognosis. The aim of the study was to categorize ACLF according to the severity of underlying chronic liver diseases.

METHODS

A total of 540 ACLF patients were recruited, including 127 with prior decompensated cirrhosis and 413 without prior decompensation (PD) including 193 with underlying chronic hepatitis and 220 with prior compensated cirrhosis. The clinical characteristics and prognosis of subgroups were compared. Cox proportional hazard model and multinominal logistic regression analysis were performed to identify significant prognostic parameters.

RESULTS

The 28-day, 3-month and 1-year survival of ACLF patients with or without PD were 58.9% versus 61.4%, 36.2 versus 52.5%, and 29.1% versus 49.6%, respectively. On multinominal logistic regression analysis or time-to-death analysis by Cox proportional hazard model, PD was significantly associated with post-28-day mortality but not within-28-day mortality. On multivariate time-to-death analysis, older age, high international normalized ratio (INR) and serum bilirubin, low levels of serum sodium and platelet count, and presence of hepatic encephalopathy (HE), upper gastrointestinal bleeding, and respiratory or circulation dysfunction were predictors of within-28-day mortality in patients without PD, whereas the risk factors in patients with PD were high INR, creatinine, presence of HE, and respiratory or circulation dysfunction.

CONCLUSION

ACLF patients with or without PD had comparable short-term prognosis but differential 1-year mortality. ACLF patients with PD were distinct from those without PD in age, types of acute insults, severity of hepatic damage, and distribution of complications, and the former group was characterized by increased delayed mortality.

Appropriate empirical antibiotic use and 30-d mortality in cirrhotic patients with bacteremia

AIM: To analyze whether prompt and appropriate empirical antibiotic (AEA) use is associated with mortality in cirrhotic patients with bacteremia.

METHODS: A total of 102 episodes of bacteremia in 72 patients with cirrhosis were analyzed. AEA was defined as a using or starting an antibiotic appropriate to the isolated pathogen at the time of bacteremia. The primary endpoint was 30-d mortality.

RESULTS: The mortality rate at 30 d was 30.4% (31/102 episodes). Use of AEA was associated with better survival at 30 d (76.5% vs 46.9%, P = 0.05), and inappropriate empirical antibiotic (IEA) use was an independent factor associated with increased mortality (OR = 3.24; 95%CI: 1.50-7.00; P = 0.003, adjusted for age, sex, Child-Pugh Class, gastrointestinal bleeding, presence of septic shock). IEA use was more frequent when the isolated pathogen was a multiresistant pathogen, and when infection was healthcare-related or hospital-acquired.

CONCLUSION: AEA use was associated with increased survival of cirrhotic patients who developed bacteremia. Strategies for AEA use, tailored according to the local epidemiological patterns, are needed to improve survival of cirrhotic patients with bacteremia.

Cirrhosis in children and adolescents: An overview

Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson's disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition.

Hepatic hepcidin protects against polymicrobial sepsis in mice by regulating host iron status

BACKGROUND

Hepcidin is a master regulator of iron metabolism primarily produced by the liver. Markedly increased hepcidin levels have been observed in septic individuals, while decreased hepatic hepcidin expression has been demonstrated in liver diseases that tend to develop into sepsis. However, the role of liver hepcidin in sepsis remains unknown.

METHODS

Mouse hepatic hepcidin expression was silenced using adenovirus-mediated hepcidin-specific short hairpin RNA injected via the tail vein. Sepsis was induced by cecal ligation and puncture, and the outcome (n = 23 for hepcidin knockdown mice, n = 15 for controls) and pathogenic changes (n = 5) related to sepsis were evaluated. The impact of alteration of iron status on the survival rate of hepatic hepcidin knockdown mice (n = 18 to 19) was also investigated.

RESULTS

Disruption of liver hepcidin expression increased serum iron level (537.8 ± 28.1 μg/dl [mean ± SD] vs. 235.9 ± 62.2 μg/dl; P < 0.05) and reduced iron content in the spleen macrophages at the steady state. Hepatic hepcidin knockdown mice not only showed increased 7-day mortality (73.9% vs. 46.7%; P < 0.05), but also had exacerbated organ damage and oxidative stress, as well as compromised host inflammatory responses and bacterial clearance at 24 h after polymicrobial sepsis. Treating the hepatic hepcidin knockdown mice with low-iron diet plus iron chelation decreased systemic iron content (serum level: 324.0 ± 67.4 μg/dl vs. 517.4 ± 13.4 μg/dl; P < 0.05) and rescued the mice from lethal sepsis (7-day survival: 36.8% vs. 83.3%; P < 0.01).

CONCLUSIONS

Hepatic hepcidin plays an important role in sepsis through regulation of iron metabolism. The findings may have potential therapeutic implications for liver diseases in which hepcidin expression is decreased.

Exploration of skin perfusion in cirrhotic patients with septic shock

BACKGROUND & AIMS

Skin perfusion alterations are early and strong predictors of death in patients with septic shock. Cirrhosis is associated with systemic vasodilation and increases mortality from septic shock. We aimed at assessing whether the mottling score and tissue oxygen saturation (StO2) could be used as early predictors of death in cirrhotic patients with septic shock.

METHODS

This observational study included cirrhotic patients with septic shock. Each 6 h during the first 24 h, we collected data reflecting macrocirculation (mean arterial pressure, heart rate, central venous pressure, and cardiac output) and organ perfusion (arterial lactate, urinary output, ScvO2, mottling score, thenar, and knee StO2). Data of 75 non-cirrhotic patients with previously reported septic shock were used as control.

RESULTS

42 cirrhotic patients were included. Mortality at day 14 was 71%. At H6, parameters reflecting macrocirculation were not associated with mortality, whereas higher arterial lactate and mottling score were associated with death. Mottling score was the strongest predictor of mortality (sensitivity=0.63, specificity=1, OR=42.4 (2.3-785.9)). At H6, knee StO2 decreased in non-survivors and predicted death (sensitivity=0.45, specificity=1). In comparison with control, mottling kinetic was different in cirrhotic patients (delayed mottling appearance in non-survivors, earlier mottling disappearance in survivors). Knee StO2 and skin perfusion, assessed by laser-Doppler, were higher in cirrhotic patients.

CONCLUSIONS

Mottling score and knee StO2 at H6 were very specific predictors of death in patients with cirrhosis and septic shock. Their sensitivity was lower in cirrhotic patients due to delayed mottling appearance and higher knee StO2 related to higher skin perfusion.

Acute-on-Chronic Liver Failure: Recent Concepts

A proportion of patients hospitalized for an acute complication of cirrhosis are at high risk of short-term death. The term Acute-on-Chronic Liver Failure (ACLF) is used to characterize these patients. Until recently there was no evidence-based definition of ACLF. In 2013 a definition has been proposed based on results of a large prospective observational European study, called "European Association for the Study of the Liver (EASL)-Chronic Liver Failure (CLIF) Consortium Acute-on-Chronic Liver Failure in Cirrhosis (CANONIC)" study. Results of this study led to elaborate new concepts about ACLF. First, it was found that ACLF is a syndrome that is distinct from mere decompensated cirrhosis. It was also shown that ACLF is a dynamic syndrome which can improve or conversely worsen. Patients who worsen die rapidly from multiorgan failures. The CANONIC study also found that identifiable precipitating events (e.g., bacterial infection, active alcoholism) are found in only 50% of cases of ACLF indicating that these events are dispensable for defining ACLF. In addition precipitating events may be initiators of ACLF but do not drive the outcome. An important concept derived from the CANONIC study is that ACLF is associated with systemic inflammation even in patients who do not have identifiable precipitating events. Finally it was found that ACLF may develop in patients without prior episodes of decompensation or in those with recent decompensation (<3 months). Moreover these patients with "early" ACLF were more severe than patients who developed ACLF after a long of history of decompensated cirrhosis.

Acute-on-Chronic Liver Failure: Recent Concepts

A proportion of patients hospitalized for an acute complication of cirrhosis are at high risk of short-term death. The term Acute-on-Chronic Liver Failure (ACLF) is used to characterize these patients. Until recently there was no evidence-based definition of ACLF. In 2013 a definition has been proposed based on results of a large prospective observational European study, called "European Association for the Study of the Liver (EASL)-Chronic Liver Failure (CLIF) Consortium Acute-on-Chronic Liver Failure in Cirrhosis (CANONIC)" study. Results of this study led to elaborate new concepts about ACLF. First, it was found that ACLF is a syndrome that is distinct from mere decompensated cirrhosis. It was also shown that ACLF is a dynamic syndrome which can improve or conversely worsen. Patients who worsen die rapidly from multiorgan failures. The CANONIC study also found that identifiable precipitating events (e.g., bacterial infection, active alcoholism) are found in only 50% of cases of ACLF indicating that these events are dispensable for defining ACLF. In addition precipitating events may be initiators of ACLF but do not drive the outcome. An important concept derived from the CANONIC study is that ACLF is associated with systemic inflammation even in patients who do not have identifiable precipitating events. Finally it was found that ACLF may develop in patients without prior episodes of decompensation or in those with recent decompensation (<3 months). Moreover these patients with "early" ACLF were more severe than patients who developed ACLF after a long of history of decompensated cirrhosis.

Measurement of serum procalcitonin levels for the early diagnosis of spontaneous bacterial peritonitis in patients with decompensated liver cirrhosis

BACKGROUND

It is difficult to diagnose spontaneous bacterial peritonitis (SBP) early in decompensated liver cirrhotic ascites patients (DCPs). The aim of the study was to measure serum procalcitonin (PCT) levels and peripheral blood leukocyte/platelet (WBC/PLT) ratios to obtain an early diagnostic indication of SBP in DCPs.

METHODS

Our cohort of 129 patients included 112 DCPs (94 of whom had infections) and 17 cases with compensated cirrhosis as controls. Bacterial cultures, ascitic fluid (AF) leukocyte and peripheral WBC/PLT counts, and serum PCT measurements at admission were carried out prior to the use of antibiotics. Receiver operating characteristic (ROC) curves were generated to test the accuracies and cut-off values for different inflammatory markers.

RESULTS

Among the 94 infected patients, 66 tested positive by bacterial culture, for which the positivity of blood, ascites and other secretions were 25.8%, 30.3% and 43.9%, respectively. Lung infection, SBP and unknown sites of infection accounted for 8.5%, 64.9% and 26.6% of the cases, respectively. Serum PCT levels (3.02 ± 3.30 ng/mL) in DCPs with infections were significantly higher than those in control patients (0.15 ± 0.08 ng/mL); p < 0.05. We used PCT ≥0.5 ng/mL as a cut-off value to diagnose infections, for which the sensitivity and specificity was 92.5% and 77.1%. The area under the curve (AUC) was 0.89 (95% confidence interval: 0.84-0.91). The sensitivity and specificity were 62.8% and 94.2% for the diagnosis of infections, and were 68.8% and 94.2% for the diagnosis of SBP in DCPs when PCT ≥2 ng/mL was used as a cut-off value. For the combined PCT and WBC/PLT measurements, the sensitivity was 76.8% and 83.6% for the diagnosis of infections or SBP in DCPs, respectively.

CONCLUSION

Serum PCT levels alone or in combination with WBC/PLT measurements seem to provide a satisfactory early diagnostic biomarker in DCPs with infections, especially for patients with SBP.

Healthcare-associated and nosocomial bacterial infections in cirrhosis: predictors and impact on outcome

BACKGROUND & AIMS

Population-based data on the occurrence of healthcare-associated (HCA) and hospital-acquired (HA) bacterial infections in cirrhosis, their predictors, and their impact on outcome are limited.

METHODS

All patients with incident cirrhosis in 2001-2010 residing in an area of 600,000 inhabitants were retrospectively identified. All serious bacterial infections (resulting in or occurring during an inpatient hospital episode) during this period were registered. Acquisition type, site of infection, occurrence of infection-related acute-on-chronic liver failure (ACLF), acute kidney injury (AKI) and bacterial resistance were analysed. Patients were followed longitudinally until death, transplant or end of 2011.

RESULTS

A total of 398 serious infections occurred in 241/633 (38%) patients. Forty-seven per cent were HCA and 21% HA. Proton pump inhibitor (PPI) use was more common in HA (80%) vs. HCA (64%) vs. community-acquired (44%) infections (P < 0.001). In regression analysis, decompensated status, use of antibiotics and PPIs at infection diagnosis were independent predictors of HCA/HA infections (P < 0.05). After adjustment for confounders, HCA/HA infections were significantly related to infection-related ACLF (P < 0.05), but not severe sepsis, AKI or infection-related mortality (P > 0.05). Antibiotic-resistant infections were more frequent among HA (17%) than HCA (6%) or community-acquired (8%) infections (P < 0.05). Antibiotic-resistant HCA/HA infections were independently related to severe sepsis (P < 0.05).

CONCLUSIONS

In a population-based cirrhotic cohort, two-thirds of serious bacterial infections were HCA or HA. Decompensated liver disease, antibiotics and PPIs were predictors of serious HCA/HA infections, which were associated with the development of ACLF. Antibiotic resistance was frequent, especially in HA infections, and contributed to risk of severe sepsis.

The chronic use of beta-blockers and proton pump inhibitors may affect the rate of bacterial infections in cirrhosis

BACKGROUND & AIMS

Bacterial infections are among the most common and life-threatening complications in cirrhosis. Qualitative and quantitative modifications of the gut microbiota, dysfunction of the intestinal barrier and multiple immune defects are factors that contribute to a pathological 'bacterial translocation' (BT), leading to a higher susceptibility to infections in cirrhotic patients. Long-term therapies, commonly adopted in cirrhotic patients, may influence BT and modify the risk of infection in these patients. To investigate the influence of chronic therapies on the prevalence and microbiological characteristics of infections in cirrhosis.

METHODS

Consecutive cirrhotic patients hospitalised from 2008 to 2013 were enrolled. All previous treatments were carefully recorded. Infections were actively sought out, patients were actively monitored for infection, and possible risk factors were evaluated.

RESULTS

Four hundred cirrhotic patients were included. The most frequent therapies were proton pump inhibitors (PPIs) (67%), non-absorbable-disaccharides (44%), beta-blockers (BBs) (39%) and non-absorbable-antibiotics (10%). Child-Pugh C (P < 0.001; OR 5; 95%CI: 2.6-9.9) and PPI therapy (P = 0.008; OR 2; 95% CI: 1.2-3.2) were found to be independent predictors of infection, and the use of BBs was a protective factor (P = 0.001; OR 0.46; 95%CI: 0.3-0.7). Cirrhotic patients with bacterial infection showed lower morbidity and mortality when taking BBs.

CONCLUSIONS

Proton pump inhibitors increase the risk of infection in cirrhosis and should not be prescribed in these patients without specific indications. In contrast, the use of BBs is associated with a lower rate of infection and attenuates the consequences of infections in cirrhotic patients.

CLIF-SOFA scoring system accurately predicts short-term mortality in acutely decompensated patients with alcoholic cirrhosis: a retrospective analysis

BACKGROUND & AIMS

Accurate prognostication of acute-on-chronic liver failure (ACLF) is essential for therapeutic decisions. Our aim was to validate a novel scoring system for predicting mortality, the chronic liver failure-sequential organ failure assessment (CLIF-SOFA), in a population of Asian patients with ACLF.

METHODS

A total of 345 patients with acutely decompensated alcoholic cirrhosis were selected for study, comparing areas under the receiver operating characteristic (AUROC) curves of CLIF-SOFA and five existing scoring systems for end-stage liver disease [model for end-stage liver disease (MELD), MELD-Na, Refit-MELD, Refit-MELD-Na, and Child-Turcotte-Pugh].

RESULTS

CLIF-SOFA displayed the highest AUROC of 0.943 significantly outperforming all five reference methods in predicting short-term mortality at Week 4 (all P < 0.001) by competing risk analysis. In 262 patients given supportive care only, the power of CLIF-SOFA to predict short-term mortality was high (AUROC: 0.952 at Week 1; 0.959 at Week 4), again surpassing the other methods (all P < 0.001). For the remaining 83 liver transplant recipients, CLIF-SOFA also excelled in predicting 12-week mortality (AUROC: 0.978); and high-grade ACLF by CLIF-SOFA was associated with prolonged postoperative mechanical support (i.e. mechanical ventilation and renal replacement therapy) and ICU stays (all P < 0.05).

CONCLUSIONS

CLIF-SOFA enables more accurate prediction of short-term mortality in patients with acutely decompensated alcoholic cirrhosis than other available scoring systems and is useful in predicting both 12-week mortality and the need for mechanical support after liver transplantation.

Baicalein protects against polymicrobial sepsis-induced liver injury via inhibition of inflammation and apoptosis in mice

Liver dysfunction has been known to occur frequently in cases of sepsis. Baicalein, the main active ingredient of the Scutellaria root, exerts anti-inflammatory and anti-apoptotic properties in endotoxic shock. However, the role of baicalein in polymicrobial sepsis-induced liver injury and its regulatory mechanisms remain unclear. In this study, we aimed to investigate the protective effects of baicalein on polymicrobial sepsis-induced liver injury and to explore the possible mechanisms. Polymicrobial sepsis was induced by cecal ligation and puncture (CLP) in C57BL/6 mice. Mice were treated with baicalein (100mg/kg, i.p) at 1h, 6h and 12h following CLP. Baicalein significantly improved the survival of septic mice. Treatment with baicalein ameliorated the CLP-induced liver injury, as indicated by the lower serum aminotransferase levels and the fewer histopathologic abnormalities. Baicalein reduced the neutrophil infiltration and the hepatic inflammatory cytokine expression and release. It also decreased the hepatic and the serum high-mobility group box 1 and macrophage migration inhibitory factor levels in septic mice. Moreover, baicalein significantly inhibited the mitogen-activated protein kinases (MAPKs) activation and suppressed the transcriptional activity of nuclear factor-kappa B (NF-κB). In conclusion, these results suggest that baicalein treatment could protect against the sepsis-induced liver injury, and improve the survival of mice with polymicrobial sepsis. The mechanism of the protective action of baicalein seems to involve its ability to reduce inflammatory response, to inhibit hepatic apoptosis, and to suppress MAPKs and NF-κB activation.

The effect of tuberculosis on the mortality of cirrhotic patients: a population-based 3-year follow-up study

Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis. It is still unknown if TB, like other infectious diseases contributes a poor prognosis in cirrhotic patients. The aim of this study was to investigate the impact of TB on the mortality of cirrhotic patients. National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify 434 cirrhotic patients with new diagnosis of TB between January 1, 2007 and December 31, 2007. The comparison group consisted of 4340 selected cirrhotic patients without TB in the same period by propensity score matching analysis. The 30-day, 90-day, 1-year and 3-year mortalities were 10.1%, 24.2%, 43.1%, and 63% in the TB group, and 7.9%, 15.5%, 31.2%, and 53.4% in the non-TB group. After Cox proportional hazard regression model adjusted by the patients' gender, age, and comorbid disorders, the hazard ratios (HR) in cirrhotic patients with TB for 30-day, 30 to 90-day, 90-day to 1-year, and 1 to 3-year mortalities were 1.33 [95% confidence interval (CI) 0.97-1.83], 1.91 (95% CI 1.45-2.51), 1.46 (95% CI 1.16-1.84), and 1.10 (95% CI 0.88-1.37), compared to the non-TB group. In conclusion, TB is a risk factor for the mortality of cirrhotic patients. The effect focused on the 30-day to 1-year after diagnosis of TB.

Extrahepatic complications to cirrhosis and portal hypertension: Haemodynamic and homeostatic aspects

In addition to complications relating to the liver, patients with cirrhosis and portal hypertension develop extrahepatic functional disturbances of multiple organ systems. This can be considered a multiple organ failure that involves the heart, lungs, kidneys, the immune systems, and other organ systems. Progressive fibrosis of the liver and subsequent metabolic impairment leads to a systemic and splanchnic arteriolar vasodilatation. This affects both the haemodynamic and functional homeostasis of many organs and largely determines the course of the disease. With the progression of the disease, the circulation becomes hyperdynamic with cardiac, pulmonary as well as renal consequences for dysfunction and reduced survival. Infections and a changed cardiac function known as cirrhotic cardiomyopathy may be involved in further aggravation of other complications such as renal failure precipitating the hepatorenal syndrome. Patients with end-stage liver disease and related complications as for example the hepatopulmonary syndrome can only radically be treated by liver transplantation. As a bridge to this treatment, knowledge on the mechanisms of the pathophysiology of complications is essential for the choice of vasoactive drugs, antibiotics, drugs with specific effects on fibrogenesis and inflammation, and drugs that target specific receptors.

mRNA expression of glucocorticoid receptor and serological and virological markers of chronic hepatitis B

Glucocorticoid receptor (GR) function is essential for glucocorticoid action on various effector cells. The aim of the present study was to investigate the mRNA expression profiles of GRα and GRβ in peripheral blood mononuclear cells (PBMC) and examine the association between the expression levels of the GR isoforms and the serological and virological hepatitis B virus (HBV) status in patients with chronic hepatitis B (CHB). A total of 29 CHB patients were examined in the present study, which were divided into subgroups according to serological and virological markers. The levels of GRα and GRβ in PBMCs, HBV viral loads, HBV surface antigen (HBsAg), HBV e antigen (HBeAg) and pre‑S1Ag were measured. A total of 43 healthy individuals served as controls. GRα was present in the PBMCs of all CHB patients and healthy controls, whereas GRβ‑specific products were present in only 93.1% of the CHB patients and 86.0% of the healthy controls. The GRα levels were positively correlated with the expression of GRβ in the CHB patients (r=0.419; P<0.05) and were significantly lower compared with those observed in the healthy controls (60.51 ± 23.73, vs. 100.00 ± 40.75; P<0.001). Compared with the healthy controls, significant differences were observed in the mRNA expression of GRα in the CHB patients when stratified according to the HBeAg, pre‑S1Ag and HBV viral load status (P<0.05), but not in the pre‑S1Ag‑positive patients. These data demonstrated that the mRNA expression profile of GRα differed between the CHB patients and the healthy controls. In addition, the HBV serological and virological markers were not associated with the mRNA levels of the GR isoforms in the CHB patients.

Intensive care unit management of patients with liver failure

Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) usually mandate management within an intensive care unit (ICU). Even though the conditions bear some similarities, precipitating causes, and systemic complications management practices differ. Although early identification of ALF and ACLF, improvements in ICU management, and the widespread availability of liver transplantation have improved mortality, optimal management practices have not been defined. This article summarizes current ICU management practices and identifies areas of management that require further study.

Impact of infection on the prognosis of critically ill cirrhotic patients: results from a large worldwide study

BACKGROUND

Infections are a leading cause of death in patients with advanced cirrhosis, but there are relatively few data on the epidemiology of infection in intensive care unit (ICU) patients with cirrhosis.

AIMS

We used data from the Extended Prevalence of Infection in Intensive Care (EPIC) II 1-day point-prevalence study to better define the characteristics of infection in these patients.

METHODS

We compared characteristics, including occurrence and types of infections in non-cirrhotic and cirrhotic patients who had not undergone liver transplantation.

RESULTS

The EPIC II database includes 13,796 adult patients from 1265 ICUs: 410 of the patients had cirrhosis. The prevalence of infection was higher in cirrhotic than in non-cirrhotic patients (59 vs. 51%, P < 0.01). The lungs were the most common site of infection in all patients, but abdominal infections were more common in cirrhotic than in non-cirrhotic patients (30 vs. 19%, P < 0.01). Infected cirrhotic patients more often had Gram-positive (56 vs. 47%, P < 0.05) isolates than did infected non-cirrhotic patients. Methicillin-resistant Staphylococcus aureus (MRSA) was more frequent in cirrhotic patients. The hospital mortality rate of cirrhotic patients was 42%, compared to 24% in the non-cirrhotic population (P < 0.001). Severe sepsis and septic shock were associated with higher in-hospital mortality rates in cirrhotic than in non-cirrhotic patients (41% and 71% vs. 30% and 49%, respectively, P < 0.05).

CONCLUSIONS

Infection is more common in cirrhotic than in non-cirrhotic ICU patients and more commonly caused by Gram-positive organisms, including MRSA. Infection in patients with cirrhosis was associated with higher mortality rates than in non-cirrhotic patients.

Fungal "colonisation" is associated with increased mortality in medical intensive care unit patients with liver cirrhosis

OBJECTIVES

Patients with liver cirrhosis are at increased risk for fungal infections. However, distinction of fungal colonisation (FC) and invasive mycoses is difficult. Aim of this study was to analyse the impact of FC on mortality of cirrhotic ICU-patients.

METHODS

Retrospective mortality analysis of a prospectively maintained database on 120 cirrhotic patients with and without FC. Comparison to 120 noncirrhotic controls matched for APACHE-II (24.9 ± 3.7 vs. 25.0 ± 2.6; p = 0.263).

RESULTS

About 69/120 (58%) of patients with cirrhosis had FC. These patients had significantly higher APACHE-II score and mortality compared to cirrhotic patients without FC (27 ± 3 vs. 23 ± 4, p < 0.001; 78 vs. 35%, p < 0.001). In multivariate analysis, FC was independently (p = 0.047) associated to mortality. Mortality of noncirrhotic patients with FC (14/31; 45.2%) was not different to noncirrhotic controls without FC [28/89 (31.2%; p = 0.168)]. Similarly, in multivariate analysis of noncirrhotics, APACHE-II (p < 0.001), but not FC, was independently associated to mortality. Multiple regression analysis of all 240 cirrhotic and noncirrhotic patients demonstrated that APACHE-II (p < 0.001), cirrhosis (p = 0.001) and FC (p = 0.049) were independently associated with mortality.

CONCLUSION

Fungal "colonisation" is independently associated to mortality in cirrhotic ICU-patients. Early antimycotic therapy should be considered in critically ill cirrhotic patients with FC.

Pentoxifylline vs. corticosteroid to treat severe alcoholic hepatitis: a randomised, non-inferiority, open trial

BACKGROUND & AIMS

Both corticosteroid and pentoxifylline reduce short-term mortality in severe alcoholic hepatitis. However, few studies have directly compared the efficacy of pentoxifylline and corticosteroid in patients with this condition.

METHODS

In this multicentre, open-labelled, randomised non-inferiority trial, we assigned 121 patients with severe alcoholic hepatitis (Maddrey's discriminant function ⩾32) to receive either pentoxifylline (400 mg, 3 times daily, in 62 subjects) or prednisolone (40 mg daily, in 59 subjects). The primary end point was non-inferiority in survival at the 1 month time point for the pentoxifylline treatment compared with prednisolone.

RESULTS

The 1-month survival rate of patients receiving pentoxifylline was 75.8% (15 deaths) compared with 88.1% (7 deaths) in those, taking prednisolone, for a treatment difference of 12.3% (95% confidence interval, -4.2% to 28.7%; p = 0.08). The 95% confidence interval for the observed difference exceeded the predefined margin of non-inferiority (Δ15%) and included zero. The 6-month survival rate was not significantly different between the pentoxifylline and prednisolone groups (64.5% vs. 72.9%; p = 0.23). At 7 days, the response to therapy assessed by the Lille model was significantly lower in the prednisolone group (n = 58) than in the pentoxifylline group (n = 5 9): 0.35 vs. 0.50 (p = 0.012). Hepatitis complications, including hepatorenal syndrome and side effects, such as infection and gastrointestinal bleeding, were similar in the two groups.

CONCLUSIONS

The findings demonstrate that the efficacy of the pentoxifylline is not statistically equivalent to the efficacy of prednisolone, supporting the use of prednisolone as a preferred treatment option in patients with severe alcoholic hepatitis.

Management of Complications of End-Stage Liver Disease in the Intensive Care Unit

The management of critically ill patients with end-stage liver disease can be challenging due to the vulnerability of this population and the wide-ranging complications of the disease. This review proposes an approach based on the major organ systems affected, to provide a framework for managing the most common complications. Although considerable practice variation exists, a focus on the evidence behind the most common practices will ensure the development of the optimal skillset to appropriately manage this disease.

Molecular detection of monocyte chemotactic protein-1 polymorphism in spontaneous bacterial peritonitis patients

AIM: To investigate the association of the functional monocyte chemotactic protein-1 (MCP-1) promoter polymorphism (A-2518G) with spontaneous bacterial peritonitis (SBP).

METHODS: Fifty patients with post-hepatitis C liver cirrhosis and ascites were categorized into two groups; group I included 25 patients with SBP and group II included 25 patients free from SBP. In addition, a group of 20 healthy volunteers were included. We assessed the MCP-1 gene polymorphism and gene expression as well as interleukin (IL)-10 levels in both blood and ascitic fluid.

RESULTS: A significant MCP-1 gene polymorphism was detected in groups I and II (P = 0.001 and 0.02 respectively). Group I was associated with a significantly higher frequency of AG genotype [control 8 (40%) vs SBP 19 (76.0%), P < 0.001], and group II was associated with a significantly higher frequency of GG genotype when compared to healthy volunteers [control 1 (5%) vs cirrhotic 16 (64%), P < 0.001]. Accordingly, the frequency of G allele was significantly higher in both groups (I and II) [control 10 (25%) vs SBP 27 (54%), P < 0.001 and vs cirrhotic 37 (74.0%), P < 0.001, respectively]. The total blood and ascetic fluid levels of IL-10 and MCP-1 gene expression were significantly higher in group I than in group II. Group I showed significant reductions in the levels of MCP-1 gene expression and IL-10 in the whole blood and ascetic fluid after therapy.

CONCLUSION: MCP-1 GG genotype and G allele may predispose HCV infected patients to a more progressive disease course, while AG genotype may increase the susceptibility to SBP. Patients carrying these genotypes should be under supervision to prevent or restrict further complications.

Kidney injury in cirrhosis: pathophysiological and therapeutic aspects of hepatorenal syndromes

Acute kidney injury (AKI) is frequent in patients with cirrhosis. AKI and hyponatraemia are major determinants of the poor prognosis in advanced cirrhosis. The hepatorenal syndrome (HRS) denotes a functional and potential reversible impairment of renal function. Type 1 HRS, a special type of AKI, is a rapidly progressive AKI, whereas the renal function in type 2 HRS decreases more slowly. HRS is precipitated by factors such as sepsis that aggravate the effective hypovolaemia in decompensated cirrhosis, by lowering arterial pressure and cardiac output and enhanced sympathetic nervous activity. Therefore, attempts to prevent and treat HRS should seek to improve liver function and to ameliorate arterial hypotension, central hypovolaemia and cardiac output, and to reduce renal vasoconstriction. Ample treatment of HRS is important to prevent further progression and death, but as medical treatment only modestly improves long-term survival, these patients should always be considered for liver transplantation. Hyponatraemia, defined as serum sodium <130 mmol/L, is common in patients with decompensated cirrhosis. From a pathophysiological point of view, hyponatraemia is related to an impairment of renal solute-free water excretion most likely caused by an increased vasopressin secretion. Patients with cirrhosis mainly develop hypervolaemic hyponatraemia. Current evidence does not support routine use of vaptans in the management of hyponatraemia in cirrhosis.

Ultra-sensitive procalcitonin may help rule out bacterial infections in patients with cirrhosis

BACKGROUND

Bacterial infections are frequent complications in patients with cirrhosis. Since they are associated with poor outcomes, antibiotics are frequently over-prescribed. Surrogate markers of bacterial infections, like procalcitonin, are needed to better discriminate between infected and not infected patients.

AIMS

To evaluated the diagnostic accuracy of an ultra-sensitive procalcitonin assay for the diagnosis of bacterial infections in patients with cirrhosis.

MATERIAL AND METHODS

In a single-center prospective study, we determined the basal levels of procalcitonin in 106 episodes of admissions to the emergency department in 84 cirrhotic patients. Patients were classified as infected or not infected by two independent hepatologists blinded to the procalcitonin result.

RESULTS

The prevalence of bacterial infection was 28% (29 episodes). The median procalcitonin was significantly higher in the infected group than in the not infected group (0.45 vs. 0.061 ng/mL, p < 0.001). The diagnostic accuracy of procalcitonin for bacterial infection estimated by the ROC curve was 0.95 (CI: 95%, 0.91-0.99). When selecting a cutoff value of 0.098 ng/mL a sensitivity of 97% and a negative predictive value 98% were found.

CONCLUSIONS

The use of an ultra-sensitive procalcitonin assay identifies patients with cirrhosis at very low risk of bacterial infections.

Mortality of patients infected with HIV in the intensive care unit (2005 through 2010): significant role of chronic hepatitis C and severe sepsis

INTRODUCTION

The combination antiretroviral therapy (cART) has led to decreased opportunistic infections and hospital admissions in human immunodeficiency virus (HIV)-infected patients, but the intensive care unit (ICU) admission rate remains constant (or even increased in some instances) during the cART era. Hepatitis C virus (HCV) infection is associated with an increased risk for hospital admission and/or mortality (particularly those related to severe liver disease) compared with the general population. The aim of this study was to assess the mortality among HIV-infected patients in ICU, and to evaluate the impact of HIV/HCV coinfection and severe sepsis on ICU mortality.

METHODS

We carried out a retrospective study based on patients admitted to ICU who were recorded in the Minimum Basic Data Set (2005 through 2010) in Spain. HIV-infected patients (All-HIV-group (n = 1,891)) were divided into two groups: HIV-monoinfected patients (HIV group (n = 1,191)) and HIV/HCV-coinfected patients (HIV/HCV group (n = 700)). A control group (HIV(-)/HCV(-)) was also included (n = 7,496).

RESULTS

All-HIV group had higher frequencies of severe sepsis (57.7% versus 39.4%; P < 0.001) than did the control group. Overall, ICU mortality in patients with severe sepsis was much more frequent than that in patients without severe sepsis (other causes) at days 30 and 90 in HIV-infected patients and the control group (P < 0.001). Moreover, the all-HIV group in the presence or absence of severe sepsis had a higher percentage of death than did the control group at days 7 (P < 0.001), 30 (P < 0.001) and 90 (P < 0.001). Besides, the HIV/HCV group had a higher percentage of death, both in patients with severe sepsis and in patients without severe sepsis compared with the HIV group at days 7 (P < 0.001) and 30 (P < 0.001), whereas no differences were found at day 90. In a bayesian competing-risk model, the HIV/HCV group had a higher mortality risk (adjusted hazard ratio (aHR) = 1.44 (95% CI = 1.30 to 1.59) and aHR = 1.57 (95% CI = 1.38 to 1.78) for patients with and without severe sepsis, respectively).

CONCLUSIONS

HIV infection was related to a higher frequency of severe sepsis and death among patients admitted to the ICU. Besides, HIV/HCV coinfection contributed to an increased risk of death in both the presence and the absence of severe sepsis.

Improved prognosis of septic shock in patients with cirrhosis: a multicenter study*

OBJECTIVE

To determine the evolution of the outcome of patients with cirrhosis and septic shock.

DESIGN

A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data.

SETTING

The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area.

PATIENTS

Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04).

CONCLUSIONS

The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.

Faecal carriage of extended-spectrumβ-lactamase (ESBL)-producing enterobacteria in liver disease patients from two hospitals in Egypt and France: a comparative epidemiological study

This study aimed to assess and compare the epidemiology of faecal carriage of extended spectrumβ-lactamase-producing enterobacteria (ESBL-E) in Hepatology departments of two hospitals specializing in liver diseases, Theodor Bilharz Research Institute (TBRI) in Cairo (Egypt) and Beaujon Hospital (Bj) in Clichy (France). CTX-M groups were identified by PCR, and TEM and SHV derivatives with the check-point system. Phylogenetic groups ofE. coliwere determined by multiplex PCR, and clone ST131 by PCR of genepabB. Prevalence of ESBL-E was 77·6% (45/58) in TBRI and 6·5% (13/199) in Bj (P < 10−7). Previous hospitalization was more common (P = 0·003) in Bj patients (93%) than in TBRI patients (45%) suggesting high prevalence of ESBL-E in the Egyptian community. The presence ofE. coliB2 ST131 among ESBL-E faecalE. coliin Egypt confirms its pervasiveness in the community and raises concern regarding this highly virulent and resistant clone.

A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver

BACKGROUND AND AIMS

Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients.

METHODS

In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated.

RESULTS

One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p = 0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI = 1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI = 2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001).

CONCLUSIONS

Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.

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.

Impairment of innate immune responses in cirrhotic patients and treatment by branched-chain amino acids

It has been reported that host defense responses, such as phagocytic function of neutrophils and natural killer (NK) cell activity of lymphocytes, are impaired in cirrhotic patients. This review will concentrate on the impairment of innate immune responses in decompensated cirrhotic patients and the effect of the treatment by branched-chain amino acids (BCAA) on innate immune responses. We already reported that phagocytic function of neutrophils was significantly improved by 3-mo BCAA supplementation. In addition, the changes of NK activity were also significant at 3 mo of supplementation compared with before supplementation. Also, Fisher’s ratios were reported to be significantly increased at 3 mo of BCAA supplementation compared with those before oral supplementation. Therefore, administration of BCAA could reduce the risk of bacterial and viral infection in patients with decompensated cirrhosis by restoring impaired innate immune responses of the host. In addition, it was also revealed that BCAA oral supplementation could reduce the risk of development of hepatocellular carcinoma in cirrhotic patients. The mechanisms of the effects will also be discussed in this review article.

Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013

Bacterial infections are very common and represent one of the most important reasons of progression of liver failure, development of liver-related complications, and mortality in patients with cirrhosis. In fact, bacterial infections may be a triggering factor for the occurrence of gastrointestinal bleeding, hypervolemic hyponatremia, hepatic encephalopathy, kidney failure, and development of acute-on-chronic liver failure. Moreover, infections are a very common cause of repeated hospitalizations, impaired health-related quality of life, and increased healthcare costs in cirrhosis. Bacterial infections develop as a consequence of immune dysfunction that occurs progressively during the course of cirrhosis. In a significant proportion of patients, infections are caused by gram-negative bacteria from intestinal origin, yet gram-positive bacteria are a frequent cause of infection, particularly in hospitalized patients. In recent years, infections caused by multidrug-resistant bacteria are becoming an important clinical problem in many countries. The reduction of the negative clinical impact of infections in patients with cirrhosis may be achieved by a combination of prophylactic measures, such as administration of antibiotics, to reduce the occurrence of infections in high-risk groups together with early identification and management of infection once it has developed. Investigation on the mechanisms of altered gut microflora, translocation of bacteria, and immune dysfunction may help develop more effective and safe methods of prevention compared to those that are currently available. Moreover, research on biomarkers of early infection may be useful in early diagnosis and treatment of infections. The current manuscript reports an in-depth review and a position statement on bacterial infections in cirrhosis.

The liver may act as a firewall mediating mutualism between the host and its gut commensal microbiota

A prerequisite for establishment of mutualism between the host and the microbial community that inhabits the large intestine is the stringent mucosal compartmentalization of microorganisms. Microbe-loaded dendritic cells trafficking through lymphatics are arrested at the mesenteric lymph nodes, which constitute the firewall of the intestinal lymphatic circulation. We show in different mouse models that the liver, which receives the intestinal venous blood circulation, forms a vascular firewall that captures gut commensal bacteria entering the bloodstream during intestinal pathology. Phagocytic Kupffer cells in the liver of mice clear commensals from the systemic vasculature independently of the spleen through the liver's own arterial supply. Damage to the liver firewall in mice impairs functional clearance of commensals from blood, despite heightened innate immunity, resulting in spontaneous priming of nonmucosal immune responses through increased systemic exposure to gut commensals. Systemic immune responses consistent with increased extraintestinal commensal exposure were found in humans with liver disease (nonalcoholic steatohepatitis). The liver may act as a functional vascular firewall that clears commensals that have penetrated either intestinal or systemic vascular circuits.

Changing options for prevention and treatment of infections in cirrhosis

OPINION STATEMENT

Bacterial infections are more frequent and severe in cirrhosis. Most prevalent infections are spontaneous bacterial peritonitis (SBP) and urinary infections followed by pneumonia, cellulitis and bacteremia. Cirrhosis increases the risk of sepsis, severe sepsis and death. Early diagnosis and adequate treatment of infections is essential in the management of cirrhotic patients. Recent data show that currently recommended empirical antibiotic therapy, mainly based on the use of β-lactams, is effective in community-acquired infections, but frequently fails in nosocomial and healthcare-associated infections. A marked increase in the prevalence of multidrug resistant (MDR) bacteria in the healthcare environment explains this finding. Patients developing nosocomial infections or with extended lengths of hospitalization are at higher risk for second infections that are associated with poor prognosis. Antibiotic strategies should therefore be selected according to the type, severity and site of acquisition of infection, and be adapted to the local epidemiological pattern of antibiotic resistance. Treatment of MDR bacteria requires the use of broader spectrum antibiotics (carbapenems) or those active against specific resistant bacteria (glycopeptides, linezolid, daptomycin, amikacin, colistin). Restriction of antibiotic prophylaxis to the high-risk populations, prevention of antibiotic overuse, and early de-escalation policies are also mandatory to prevent the spread of MDR bacteria in cirrhosis.

Impact of rifaximin on the frequency and characteristics of spontaneous bacterial peritonitis in patients with liver cirrhosis and ascites

Background

Rifaximin is a non-absorbable antibiotic used to prevent relapses of hepatic encephalopathy which may also be a candidate for prophylaxis of spontaneous bacterial peritonitis (SBP).

Aim

To detect the impact of rifaximin on the occurrence and characteristics of SBP.

Methods

We prospectively studied all hospitalized patients that underwent a diagnostic paracentesis in our department from March 2012 to April 2013 for SBP and recorded all clinical data including type of SBP prophylaxis, prior use of rifaximin, concomitant complications of cirrhosis, as well as laboratory results and bacteriological findings. Patients were divided into the following three groups: no antibiotic prophylaxis, prophylaxis with rifaximin or with systemically absorbed antibiotic prophylaxis.

Results

Our study cohort comprised 152 patients with advanced liver cirrhosis, 32 of whom developed SBP during the study period. As expected, our study groups differed regarding a history of hepatic encephalopathy and SBP before inclusion into the study. None of the 17 patients on systemic antibiotic prophylaxis developed SBP while 8/27 patients on rifaximin and 24/108 without prophylaxis had SBP (p = 0.02 and p = 0.04 versus systemic antibiotics, respectively). In general, episodes of SBP were similar for patients treated with rifaximin and those without any prophylaxis. However, Escherichia coli and enterococci were dominant in the ascites of patients without any prophylaxis, while mostly klebsiella species were recovered from the ascites samples in the rifaximin group.

Conclusion

Rifaximin pretreatment did not lead to a reduction of SBP occurrence in hospitalized patients with advanced liver disease. However, the bacterial species causing SBP were changed by rifaximin.

Therapeutic plasma exchange as rescue therapy in severe sepsis and septic shock: retrospective observational single-centre study of 23 patients

BACKGROUND

Several case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis. However, the exact role of TPE in modern sepsis therapy remains unclear.

METHODS

We performed a retrospective observational single-centre study on the use of TPE as rescue therapy in 23 consecutive patients with severe sepsis or septic shock from 2005 to 2012. Main surrogate markers of multiple organ failure (MOF) before, during and after TPE as well as survival rates are reported.

RESULTS

At baseline, mean SOFA score was 13 (standard deviation [SD] 4) and median number of failed organ-systems was 5 (interquartile range [IQR] 4-5). TPEs were performed 3 days (IQR 2-10) after symptom onset and 1 day (IQR 0-8) after ICU admission. The median total exchange volume was 3750 ml (IQR 2500-6000), which corresponded to a mean of 1.5 times (SD 0.9) the individual plasma volume. Fresh frozen plasma was used in all but one treatments as replacement fluid. Net fluid balance decreased significantly within 12 hrs following the first TPE procedure by a median of 720 mL (p = 0.002), irrespective of outcome. Reductions of norepinephrine dose and improvement in cardiac index were observed in individual survivors, but this was not significant for the overall cohort (p = 0.574). Platelet counts decreased irrespective of outcome between days 0 and 2 (p < 0.003), and increased thereafter in many survivors. There was a non-significant trend towards younger age and higher procalcitonin levels among survivors. Nine out of 23 TPE treated patients (39%) survived until ICU discharge (among them 3 patients with baseline SOFA scores of 15, 17, and 20).

CONCLUSIONS

Our data suggest that some patients with severe sepsis and septic shock may experience hemodynamic stabilisation by early TPE therapy.

The role of the liver in sepsis

Despite the progress made in the clinical management of sepsis, sepsis morbidity and mortality rates remain high. The inflammatory pathogenesis and organ injury leading to death from sepsis are not fully understood for vital organs, especially the liver. Only recently has the role of the liver in sepsis begun to be revealed. Pre-existing liver dysfunction is a risk factor for the progression of infection to sepsis. Liver dysfunction after sepsis is an independent risk factor for multiple organ dysfunction and sepsis-induced death. The liver works as a lymphoid organ in response to sepsis. Acting as a double-edged sword in sepsis, the liver-mediated immune response is responsible for clearing bacteria and toxins but also causes inflammation, immunosuppression, and organ damage. Attenuating liver injury and restoring liver function lowers morbidity and mortality rates in patients with sepsis. This review summarizes the central role of liver in the host immune response to sepsis and in clinical outcomes.

Correction of all-trans retinoic acid deficiency in alcoholic cirrhosis lessens the excessive inflammatory monocyte response: a translational study

BACKGROUND & AIMS

Patients with alcoholic liver disease (ALD) have vitamin A (VA) deficiency and an enhanced immune response associated with disease severity. All-trans retinoic acid (ATRA), a VA-active metabolite, has anti-inflammatory effects and its deficiency could contribute to the exacerbated proinflammatory reaction. The aim of this study was to investigate the effects of ATRA/VA deficiency and supplementation on the monocyte response in ALD.

METHODS

Vitamin A and ATRA plasma levels were quantified in ALD patients and healthy subjects (HS). The in vitro effect of ATRA on lipopolysaccharide (LPS)-induced TNF-α production by human peripheral blood mononuclear cells (PBMC) was assessed by ELISA and RT-PCR. The activation pattern of peritoneal macrophages (PerMΦ) and circulating monocytes isolated from VA-deficient mice and ALD patients, respectively, was evaluated by flow cytometry, quantification of TNF-α and NO2 production.

RESULTS

Alcoholic liver disease patients (n = 85) showed plasmatic VA deficiency that was correlated with scores of severity and with the hepatic venous pressure gradient. ATRA levels correlated significantly with VA levels. In vitro, ATRA pretreatment decreased the overproduction of TNF-α by LPS-stimulated PBMC of ALD patients. In vivo, VA deficiency in mice was associated with increased activation of PerMΦ, while oral ATRA supplementation normalized it.

CONCLUSION

For the first time, we show that VA/ATRA deficiencies in ALD patients are associated with disease severity. Furthermore, our data strongly suggest that the VA deficiency observed in ALD patients might participate in the pathophysiology of the disease by priming immune cells, and that ATRA supplementation could downregulate the deleterious proinflammatory state in cirrhosis and might thus be of therapeutic use.

Management of infections in cirrhotic patients: report of a consensus conference

The statements produced by the consensus conference on infection in end-stage liver disease promoted by the Italian Association for the Study of the Liver, are here reported. The topics of epidemiology, risk factors, diagnosis, prophylaxis, and treatment of infections in patient with compensated and decompensated liver cirrhosis were reviewed by a scientific board of experts who proposed 26 statements that were graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. By systematic literature search of available evidence, comparison and discussion of expert opinions, pertinent statements answering specific questions were presented and approved. Short comments were added to explain the basis for grading evidence particularly on case of controversial areas.

Acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is an increasingly recognized distinct disease entity encompassing an acute deterioration of liver function in patients with chronic liver disease. Although there are no widely accepted diagnostic criteria for ACLF, the Asia.Pacific Association for the Study of the Liver (APASL) and the American Association for the Study of Liver Disease and the European Association for the Study of the Liver (AASLD/EASL) consensus definitions are commonly used. It is obvious that the APASL and the AASLD/EASL definitions are based on fundamentally different features. Two different definitions in two different parts of the world hamper the comparability of studies. Recently, the EASL-Chronic Liver Failure Consortium proposed new diagnostic criteria for ACLF based on analyses of patients with organ failure. There are areas of uncertainty in defining ACLF, such as heterogeneity of ACLF, ambiguity in qualifying underlying liver disease, argument for infection or sepsis as a precipitating event, etc. Although the exact pathogenesis of ACLF remains to be elucidated, alteration of host response to injury, infection, and unregulated inflammation play important roles. The predisposition, infection/inflammation, response, organ failure (PIRO) concept used for sepsis might be useful in describing the pathophysiology and clinical categories for ACLF. Treatment strategies are limited to organ support but better understanding of the pathophysiology is likely to lead to discovery of novel biomarkers and therapeutic strategies in the future.