1
|
Johansen S, Langkjær S, Rasmussen DN, Israelsen M, Torp N, Lindvig K, Kjærgaard M, Hansen JK, Hansen CD, Thorhauge K, Andersen P, Detlefsen S, Juel HB, Justesen US, Hansen T, Krag A, Thiele M. Infections increase the risk of decompensation and death in patients with early alcohol-related liver disease. JHEP Rep 2024; 6:101016. [PMID: 38486819 PMCID: PMC10937840 DOI: 10.1016/j.jhepr.2024.101016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/19/2023] [Accepted: 01/16/2024] [Indexed: 03/17/2024] Open
Abstract
Background & Aims Infections are frequent in patients with cirrhosis and worsen prognosis. We evaluated the incidence of infections and their impact on decompensation and death in patients with early alcohol-related liver disease (ALD) during long-term follow-up. Methods We performed a prospective cohort study of patients in secondary care with a history of excess alcohol intake, no prior decompensation, and with liver biopsies along with clinical investigations conducted at baseline. During follow-up, we reviewed the patients' electronic healthcare records for cases of infections, hospitalizations, transient elastography measurements, decompensations, all-cause mortality, and alcohol intake. Results We included 461 patients with a mean age of 56±10 years (76% males; fibrosis stage F0-1/F2/F3-4 = 259/107/93 [56%/23%/20%]). During a median follow-up of 4.5 years (IQR 2.9-6.3), 134 patients (29%) developed a total of 312 infections, most frequently pneumonia (106/312, 34%) and urinary tract infections (57/312, 18%). Excessive alcohol intake during follow-up, smoking ≥30 pack years, MELD score and elevated liver stiffness during follow-up were independent predictors of infections. Patients who developed at least one infection had a significantly increased risk of subsequent decompensation (hazard ratio 4.98, 95% CI 2.47-10.03) and death (hazard ratio 8.24, 95% CI 4.65-14.59). Infections increased the risk of decompensation and death independently of baseline fibrosis stage, age, gender, and MELD score. Conclusions Almost one-third of patients with early ALD develop an infection, which worsens their prognosis by increasing the risk of decompensation and death. The risk of infections increases with liver disease severity and ongoing harmful use of alcohol. Impact and implications This study reveals that infections significantly worsen the prognosis of patients with early alcohol-related liver disease (ALD), increasing the likelihood of decompensation and death by up to eight times. These findings, pertinent to healthcare providers, researchers, and policymakers, emphasize the importance of early prevention and management of infections in patients with ALD, even those in early stages who may be asymptomatic. It was observed that nearly one-third of patients with early-stage ALD developed infections over 4.5 years, with risk factors including alcohol overuse, smoking, and higher MELD scores. The research underscores the critical need to incorporate these insights into clinical practice and public health policies to improve patient outcomes and mitigate the impact of infections in patients with ALD.
Collapse
Affiliation(s)
- Stine Johansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Simon Langkjær
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ditlev Nytoft Rasmussen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mads Israelsen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Nikolaj Torp
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Lindvig
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Kjærgaard
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Johanne Kragh Hansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Camilla Dalby Hansen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Katrine Thorhauge
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Peter Andersen
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Helene Bæk Juel
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Ulrik Stenz Justesen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Denmark
| | - Aleksander Krag
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maja Thiele
- Fibrosis, fatty liver and steatohepatitis research center Odense (FLASH), Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
2
|
Thiele M, Moreno C. Novel interventions against alcohol-related liver disease. Nat Rev Gastroenterol Hepatol 2024; 21:78-79. [PMID: 38081932 DOI: 10.1038/s41575-023-00877-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Maja Thiele
- FLASH Center for Liver Research, Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark.
- Department for Clinical Medicine, University of Southern Denmark, Odense, Denmark.
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
3
|
Agrawal D, Ravula PK, Verma G. An unusual opportunistic infection causing lower gastrointestinal tract bleeding in a patient with severe alcoholic hepatitis, post-liver transplantation. Transpl Infect Dis 2023; 25:e14062. [PMID: 37073834 DOI: 10.1111/tid.14062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Dhiraj Agrawal
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hyderabad, Telangana, India
| | - Phani Krishna Ravula
- Department of Surgical Gastroenterology, PACE Hospitals, Hyderabad, Telangana, India
| | - Govind Verma
- Department of Gastroenterology and Hepatology, PACE Hospitals, Hyderabad, Telangana, India
| |
Collapse
|
4
|
Arab JP, Addolorato G, Mathurin P, Thursz MR. Alcohol-Associated Liver Disease: Integrated Management With Alcohol Use Disorder. Clin Gastroenterol Hepatol 2023; 21:2124-2134. [PMID: 36858144 DOI: 10.1016/j.cgh.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 03/03/2023]
Abstract
Alcohol-associated liver disease (ALD) is the most common cause of cirrhosis and liver-related mortality in many regions worldwide. Around 75% of patients with cirrhosis are unaware of their disease until they are referred to the emergency department. An innovative, noninvasive screening approach is required for an earlier diagnosis of liver fibrosis. In patients with ALD the physician is inevitably dealing with 2 major disorders: the liver disease itself and the alcohol use disorder (AUD). Focus only on the liver disease will inevitably lead to failure because transient improvements in liver function are rapidly overturned if the patient returns to alcohol consumption. For this reason, integrated models of care provided by hepatologists and addiction specialists are an effective approach, which are, however, not widely available. There are multiple pharmacologic and non-pharmacologic therapies for AUD. Progress has recently been made in the management of patients with severe AH who have improved survival through better understanding of the concept of response to medical treatment, improved survival prediction, and the advent of early liver transplantation. The emerging concept is that listing for transplantation a patient with severe ALD could lead to adjusting the duration of abstinence according to the severity and evolution of liver dysfunction and the patient's addictive profile.
Collapse
Affiliation(s)
- Juan P Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Giovanni Addolorato
- Department of Medical and Surgical Sciences, Internal Medicine and Hepatology Unit, Catholic University of Rome, Rome, Italy
| | - Philippe Mathurin
- Service des maladies de l'appareil digestif, Hôpital Huriez, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Mark R Thursz
- Division of Digestive Diseases, Imperial College, London, United Kingdom
| |
Collapse
|
5
|
Munankami S, Amin S, Shrestha M, Paudel R, Pokhrel A. Alcoholic Hepatitis Mimicking Iron Overload Disorders With Hyperferritinemia and Severely Elevated Transferrin Saturation: A Case Report. Cureus 2023; 15:e41727. [PMID: 37575743 PMCID: PMC10415023 DOI: 10.7759/cureus.41727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Iron overload disorders can present as non-specific symptoms and develop gradually but, if untreated, can be very fatal. The common causes include multiple blood transfusions for chronic anemia and increased iron absorption, including hereditary hemochromatosis (HH). HH is one of the common causes of iron overload disorders and usually presents with liver cirrhosis in a setting of significantly elevated ferritin and elevated transferrin saturation. Alcoholic hepatitis is a clinical syndrome of progressive inflammatory liver injury associated with long-term heavy intake of ethanol. However, in patients with alcohol abuse, excessive alcohol consumption can disrupt iron metabolism releasing large amounts of iron into circulation. This can cause severely elevated ferritin due to disruption of iron metabolism, simulating iron overload disorders such as HH, especially if the patient also has liver cirrhosis. Even though a high transferrin saturation of greater than 45% is recommended as a cutoff transferrin value as high sensitivity for detecting iron overload disorders, it has a low specificity and positive predictive value and often identifies people with other causes of acutely elevated ferritin levels such as alcohol liver disease and hepatitis. Recognizing this feature and timely management can spare the patient from unnecessary phlebotomies and prompt treatment for alcoholic hepatitis. We present an interesting case of severe alcoholic hepatitis mimicking HH with severely elevated ferritin levels and transferrin saturation with underlying liver cirrhosis.
Collapse
Affiliation(s)
| | - Shefali Amin
- Internal Medicine, Reading Tower Health, Reading, USA
| | | | - Rubina Paudel
- Internal Medicine, Reading Tower Health, Reading, USA
| | - Arpan Pokhrel
- Internal Medicine, Reading Tower Health, Reading, USA
| |
Collapse
|
6
|
Forrest E, Bernal W. The Role of Prophylactic Antibiotics for Patients With Severe Alcohol-Related Hepatitis. JAMA 2023; 329:1552-1553. [PMID: 37159045 DOI: 10.1001/jama.2023.1729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Ewan Forrest
- Department of Gastroenterology, Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland
| | - William Bernal
- Institute of Liver Studies, Kings College Hospital, University of London, London, England
| |
Collapse
|
7
|
Affiliation(s)
- Ramon Bataller
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Juan Pablo Arab
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| | - Vijay H Shah
- From the Liver Unit, Hospital Clínic de Barcelona, Barcelona (R.B.); Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago (J.P.A.); the Division of Gastroenterology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, and London Health Sciences Centre, London, ON, Canada (J.P.A.); and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN (V.H.S.)
| |
Collapse
|
8
|
Are Cirrhotic Patients Receiving Invasive Mechanical Ventilation at Risk of Abundant Microaspiration. J Clin Med 2022; 11:jcm11205994. [PMID: 36294314 PMCID: PMC9604551 DOI: 10.3390/jcm11205994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
Abstract
Previous studies have identified cirrhosis as a risk factor for ventilator-associated pneumonia (VAP). The aim of our study was to determine the relationship between cirrhosis and abundant gastric-content microaspiration in intubated critically ill patients. We performed a matched cohort study using data from three randomized controlled trials on abundant microaspiration in patients under mechanical ventilation. Each cirrhotic patient was matched with three to four controls for gender, age ± 5 years and simplified acute physiology score II (SAPS II) ± 5 points. Abundant microaspiration was defined by significant levels of pepsin and alpha-amylase in >30% of tracheal aspirates. All tracheal aspirates were collected for the first 48 h of the study period. The percentage of patients with abundant gastric-content microaspiration was the primary outcome. The abundant microaspiration of oropharyngeal secretions, VAP incidence, the duration of mechanical ventilation, length of intensive care unit (ICU) stay and mortality were the secondary outcomes. A. total of 39 cirrhotic patients were matched to 138 controls. The percentage of patients with abundant gastric-content microaspiration did not differ between the two groups (relative risk: 0.91 (95% CI: 0.75 to 1.10)). There was no significant difference between the two groups in terms of the abundant microaspiration of oropharyngeal secretions, VAP, the duration of mechanical ventilation, the length of ICU stay and mortality. Our results suggest that cirrhosis is not associated with abundant gastric-content microaspiration.
Collapse
|
9
|
Kaur B, Rosenblatt R, Sundaram V. Infections in Alcoholic Hepatitis. J Clin Transl Hepatol 2022; 10:718-725. [PMID: 36062291 PMCID: PMC9396323 DOI: 10.14218/jcth.2022.00024] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/11/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
Severe alcoholic hepatitis (sAH) is defined by a modified discriminant function ≥32 or model for end-stage liver disease (MELD) >20. Patients with sAH are in an immunocompromised state attributed to cirrhosis-related immunoparesis and corticosteroid use. Individuals with sAH often develop severe infections that adversely impact short-term prognosis. Currently, the corticosteroid prednisolone is the only treatment with proven efficacy in sAH; however, the combination of corticosteroid treatment and altered host defense in sAH has been thought to increase the risk of acquiring of bacterial, opportunistic fungal, and viral infections. Newer studies have shown that corticosteroids do not increase occurrence of infections in those with sAH; unfortunately, the lack of response to corticosteroids may instead predispose to infection development. Prompt and appropriate antibiotic treatment is therefore essential to improving patient outcomes. This review highlights common infections and risk factors in patients with sAH. Additionally, current diagnostic, therapeutic, and prophylactic strategies in these patients are discussed.
Collapse
Affiliation(s)
- Bhupinder Kaur
- Internal Medicine Department, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Russell Rosenblatt
- Department of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USA
| | - Vinay Sundaram
- Department of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Correspondence to: Vinay Sundaram, Department of Gastroenterology and Hepatology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, 8635W. Third Street, Suite 1060W, Los Angeles, CA 90048, USA. ORCID: https://orcid.org/0000-0002-1450-7756. Tel: +1-310-423-6000, Fax: +1-310-423-6086, E-mail:
| |
Collapse
|
10
|
Otero Sanchez L, Karakike E, Moreno C, Trépo E, Gustot T. REPLY. Hepatology 2021; 74:2927-2928. [PMID: 34260763 DOI: 10.1002/hep.32057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Lukas Otero Sanchez
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Eleni Karakike
- Clinic of Infectious Diseases, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Christophe Moreno
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Eric Trépo
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium
| | - Thierry Gustot
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, C.U.B. Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium.,Inserm Unité 1149, Centre de recherche sur l'inflammation, Paris, France.,UMR S_1149, Université Paris Diderot, Paris, France
| |
Collapse
|
11
|
Jindal A. Letter to the Editor: Infections in Severe Forms of Alcohol-Associated Liver Disease: Need a Closer Look! Hepatology 2021; 74:2926-2927. [PMID: 34260765 DOI: 10.1002/hep.32058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| |
Collapse
|