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

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

Immune Dysfunction and Infection Risk in Advanced Liver Disease

The risk of microbial infections is increased in cirrhosis and other forms of advanced liver disease such as alcohol-associated hepatitis. Such infections may precipitate new or further decompensation and death, especially in patients with clinical features of acute-on-chronic liver failure. The severe immune dysfunction or "immune paralysis" caused by advanced liver disease is associated with high short-term mortality. However, the pathogenic mechanisms underlying immune dysfunction and immunodeficiency are incompletely understood. Evidence to date suggests a complex, dynamic process that perturbs the physiological roles of the liver as a master regulator of systemic immunity and protector against noxious effects of exogenous molecules in the portal vein flowing from the gut. Thus, in cirrhosis and severe alcohol-associated hepatitis, the ability of hepatocytes and intrahepatic immune cells to balance normal context-dependent dichotomous responses of tolerance vs immune activation is lost. Contributing factors include loss of the gut barrier with translocation of microbial products through the portal vein, culminating in development of functional defects in innate and adaptive immune cells, and generation of immune-regulatory myeloid cells that permit microbial colonization and infection. This review addresses key evidence supporting the paradigm of immune dysfunction as a risk for microbial infections and identifies potential therapeutic targets for intervention. The primary focus is on cirrhosis-associated immune dysfunction and alcohol-associated liver disease, because the bulk of available data are from these 2 conditions.

Bacterial Infections in Patients With Severe Alcohol-Associated Hepatitis: Drivers of Organ Failure and Mortality

BACKGROUND

Severe alcohol-associated hepatitis (sAH) is a life-threatening condition with limited treatment options. Although corticosteroids offer some benefit in short-term survival, their use remains controversial due to concerns about increased infection risk. Infections are a major cause of mortality in sAH; however, the reasons for this remain unclear.

METHODS

A post hoc analysis of the prospective VTL-308 multicentre trial on 151 patients with sAH was performed. Competing-risk models evaluated predictors of infections, the influence of corticosteroids on infection risk, and the impact of infections on the clinical outcomes up to 1 year of follow-up.

RESULTS

Among 151 patients, 90 (59.6%) developed infections. The most frequent were urinary tract (34.4%) and bloodstream (30%) infections. The causative pathogen was isolated in 40 patients, with Enterococcus spp. being the most common (35%). Fungal infections were detected in 19 (12.6%) patients. Corticosteroid use was not associated with increased bacterial (subdistribution-hazard ratio [sHR] =0.74; 95% Confidence Interval (CI): 0.42-1.33; p = 0.32) or fungal infection risk (sHR = 1.74; 95% CI: 0.59-5.15; p = 0.31). Infections significantly increased multi-organ failure (MOF) in the univariate (sHR = 2.31; 95% CI: 1.03-5.17; p = 0.04) and multivariate models (sHR = 2.46; 95% CI: 1.12-5.39; p = 0.03). 37.8% of infected patients died versus 13.1% of non-infected patients. Bacterial infections strongly predicted mortality, with sHRs ranging from 5.22 to 7.78, indicating a five- to eight-fold increased risk of death (p < 0.001).

CONCLUSIONS

Infections in sAH are central drivers of MOF and mortality. Our findings highlight infections as an independent risk factor unaffected by corticosteroid use, addressing previous concerns about the safety of this treatment.

In Vitro Immune Response of Mononuclear Cells to Multidrug-Resistant Escherichia coli

Infections caused by multidrug-resistant organisms (MDRO) are linked to poor outcomes, particularly in patients with cirrhosis. The underlying mechanisms are not fully understood and may involve a different immune response against MDRO. This study aimed to compare the in vitro immune response between multidrug-resistant (MDR) Escherichia coli and antibiotic-susceptible E. coli strains. Surface protein extract and DNA extract were obtained from MDR E. coli (n = 6) and antibiotic-susceptible E. coli (n = 6) strains isolated from infected patients with cirrhosis. The extracts were used to stimulate in vitro peripheral blood mononuclear cells from healthy donors. After 48 h, cytokine levels (IFN-γ, IL-1β, IL-10, IL-12p70, MCP-1, IL-8, IL-6, MIP-1α, and MIP-1β) were measured. We observed no significant differences in cytokine production between MDR and susceptible strains. However, we identified notable interindividual variability in cytokine production for most of the cytokines studied. Only IFN-γ and IL-6 in surface extract and MCP-1 in DNA extract showed similar levels across all donors. We conclude that the cytokine profiles induced by MDR E. coli in vitro were similar to those in susceptible strains. These findings suggest that the poor prognosis associated with MDR E. coli infections is not due to a differential immune response but rather to other factors.

Comparison of Bacterial Infections in Patients With Cirrhosis Between Hospitals With and Without Liver Transplant in Catalonia

BACKGROUND AND AIMS

Infections by multidrug resistant (MDR) bacteria are increasing and vary across regions and hospitals. We aimed to assess the epidemiology, prevalence, and outcomes of bacterial infections in patients with decompensated cirrhosis, comparing liver transplant (LT) and non-LT centers in Catalonia.

METHODS

This is a multicenter retrospective study including all patients with decompensated cirrhosis and bacterial infections hospitalised between January 2021 and 2022 from 5 university hospitals in the Barcelona metropolitan area. Two of them were LT centres. Clinical, laboratory, microbiological data, and in-hospital mortality were collected.

RESULTS

A total of 576 infections were reported in 352 patients. LT centers had more health-related infections, recurrent infections, and septic shock than non-LT centers, while there were no differences in cirrhosis severity, acute-on-chronic liver failure (ACLF) or comorbidities. Although the most commonly isolated microorganisms and types of infection were similar in both centers, LT centers had higher rates of extended-spectrum beta-lactamase (12% vs. 6%), carbapenem (3% vs. 0%) and piperacillin-tazobactam resistant bacteria (14% vs. 7%). MDR rate was also higher in LT centers (38% vs. 25%, p = 0.02) and varied across hospitals (18%-42%, p < 0.05). Furthermore, in-hospital mortality was higher in LT centers (20% vs. 10%; p = 0.01). Independent predictors of in-hospital mortality were septic shock, ACLF, Child-Pugh, age, and leukocyte count.

CONCLUSIONS

Our study showed differences in epidemiology, prevalence of MDR infections, and outcomes across university hospitals, particularly between centers with and without LT. Further studies are warranted to unveil the nuances of bacterial infections across different healthcare institutions in Europe and elsewhere.

Decompensated cirrhosis: an update of the BSG/BASL admission care bundle

Acute decompensated cirrhosis (DC) and acute-on-chronic liver failure are common reasons for hospital admission that have a high in-hospital mortality rate (10%–20%). Patients require a detailed assessment for precipitating factors and management of complications such as infections, ascites, acute kidney injury and hepatic encephalopathy. Multiple reports have demonstrated unwarranted variability in the care of patients with DC. In 2014, the British Society of Gastroenterology (BSG)/British Association for the Study of the Liver (BASL) DC care bundle (DCCB) was introduced to provide a structured approach for the management of patients with DC in the first 24 hours. Usage of the DCCB has been shown to improve care of patients with DC. However, despite evidence indicating the beneficial impact of the DCCB, overall usage across the UK was only 11.4% in a national audit. Our aim was to update the DCCB to incorporate recent advances in care and improve its usability and develop a strategy to improve its usage nationally. The updated bundle was developed by a multidisciplinary group of specialists from BSG, BASL and the Society for Acute Medicine with the quality of evidence supporting the bundle recommendations assessed using the Grading of Recommendation Assessment Development and Evaluation tool. Proposed minimum standards for audit were also developed. Finally, a strategy to promote usage of the bundle including education/training at a national and local level, improving accessibility for the bundle, and promotion of frameworks for use at an institutional level to improve and monitor utilisation of DCCB.

Hepatic Encephalopathy and MELD-Na Predict Treatment Benefit in Autoimmune Hepatitis-related Decompensated Cirrhosis

BACKGROUND & AIMS

Management of patients with autoimmune hepatitis (AIH)-related decompensated cirrhosis is challenging because of the risk of treatment-related complications and lack of clinical recommendations. We investigated the predictive factors for treatment benefit in AIH-related decompensated cirrhosis at diagnosis and developed an algorithm to guide treatment decisions in clinical practice.

METHODS

This retrospective, international, multicenter study included 232 patients with histologically confirmed AIH-related decompensated cirrhosis at diagnosis. The sub-hazard ratio (SHR) of mortality was determined by competing risk analysis, considering liver transplantation (LT) as competing event. A decision tree analysis was used to develop a treatment algorithm.

RESULTS

At diagnosis, 89% of patients had ascites, and 41% had overt hepatic encephalopathy (OHE). Treated patients (n = 214; 92%) had higher aminotransferases, bilirubin, and modified hepatic activity index. The SHR of mortality was lower in treated patients (0.438; 95% confidence interval [CI], 0.196-0.981; P = .045). Patients without OHE grade 3/4 and Model for End-Stage Liver Disease-Sodium (MELD-Na) ≤28 at diagnosis were more likely to benefit from treatment. In these patients, a decline in MELD-Na ≥11 after 4 weeks of treatment had a 100% negative predictive value for death/LT. Forty-nine percent of treated patients recompensated during follow-up. Twenty percent of patients had to discontinue treatment, 65% during the first 4 weeks, and only 4% due to infectious complications. OHE ≥grade 2 and MELD-Na at diagnosis predicted the need for treatment discontinuation.

CONCLUSIONS

Immunosuppression is beneficial in patients with AIH-related decompensated cirrhosis and active disease. OHE and MELD-Na at diagnosis, along with a decline in MELD-Na at 4 weeks of treatment, are the most important determinants of outcome and can guide treatment decisions.

Oral-gut microbiome interactions in advanced cirrhosis: characterisation of pathogenic enterotypes and salivatypes, virulence factors and antimicrobial resistance

BACKGROUND & AIMS

Cirrhosis complications are often triggered by bacterial infections with multidrug-resistant organisms. Alterations in the gut and oral microbiome in decompensated cirrhosis (DC) influence clinical outcomes. We interrogated: (i) gut and oral microbiome community structures, (ii) virulence factors (VFs) and antimicrobial resistance genes (ARGs) and (iii) oral-gut microbial overlap in patients with differing cirrhosis severity.

METHODS

Fifteen healthy controls (HCs), as well as 26 patients with stable cirrhosis (SC), 46 with DC, 14 with acute-on-chronic liver failure (ACLF) and 14 with severe infection without cirrhosis participated. Metagenomic sequencing was undertaken on paired saliva and faecal samples. 'Salivatypes' and 'enterotypes' based on genera clustering were assessed against cirrhosis severity and clinical parameters. VFs and ARGs were evaluated in oral and gut niches, and distinct resistotypes identified.

RESULTS

Salivatypes and enterotypes revealed a greater proportion of pathobionts with concomitant reduction in autochthonous genera with increasing cirrhosis severity and hyperammonaemia. Increasing overlap between oral and gut microbiome communities was observed in DC and ACLF vs. SC and HCs, independent of antimicrobial, beta-blocker and gastric acid-suppressing therapies. Two distinct gut microbiome clusters harboured genes encoding for the PTS (phosphoenolpyruvate:sugar phosphotransferase system) and other VFs in DC and ACLF. Substantial ARGs (oral: 1,218 and gut: 672) were detected (575 common to both sites). The cirrhosis resistome was distinct, with three oral and four gut resistotypes identified, respectively.

CONCLUSIONS

The degree of oral-gut microbial community overlap, frequency of VFs and ARGs all increase significantly with cirrhosis severity, with progressive dominance of pathobionts and loss of commensals. Despite similar antimicrobial exposure, patients with DC and ACLF have reduced microbial richness compared to patients with severe infection without cirrhosis, supporting the additive pathobiological effect of cirrhosis.

IMPACT AND IMPLICATIONS

This research underscores the crucial role of microbiome alterations in the progression of cirrhosis in an era of escalating multidrug resistant infections, highlighting the association and potential impact of increased oral-gut microbial overlap, virulence factors, and antimicrobial resistance genes on clinical outcomes. These findings are particularly significant for patients with decompensated cirrhosis and acute-on-chronic liver failure, as they reveal the intricate relationship between microbiome alterations and cirrhosis complications. This is relevant in the context of multidrug-resistant organisms and reduced oral-gut microbial diversity that exacerbate cirrhosis severity, drive hepatic decompensation and complicate treatment. For practical applications, these insights could guide the development of targeted microbiome-based therapeutics and personalised antimicrobial regimens for patients with cirrhosis to mitigate infectious complications and improve clinical outcomes.

Cracking the code of HBV persistence: cutting-edge approaches to targeting cccDNA in chronic hepatitis B with or without pyogenic liver Abscesses

Chronic Hepatitis B Virus (HBV) infection remains a formidable global health challenge, driving severe liver complications such as hepatocellular carcinoma (HCC) and pyogenic liver abscesses (PLA). At the core of HBV persistence lies covalently closed circular DNA (cccDNA), a viral reservoir that fuels ongoing infection despite antiviral treatments. This review highlights molecular mechanisms governing cccDNA formation, maintenance, and clearance, spotlighting innovative therapeutic strategies to disrupt this key viral element. We explore cutting-edge approaches, including epigenetic modulation to silence cccDNA, RNA interference (RNAi) for viral RNA degradation, and CRISPR/Cas genome editing to excise cccDNA directly. Additionally, emerging antiviral therapies and immunotherapies, such as therapeutic vaccines and immune checkpoint inhibitors, offer new avenues for enhanced treatment efficacy. Special attention is given to the clinical complexities of managing HBV in patients with co-morbid conditions like HCC and PLA, emphasizing the necessity of a multidisciplinary approach. The interplay between antibacterial and antiviral therapies in PLA-associated HBV cases is critically examined to prevent treatment antagonism, ensuring optimal patient outcomes. Advanced therapeutic strategies, including nucleos(t)ide analogs, interferon therapy, and novel genomic interventions, are explored in both isolated HBV infection and PLA co-infections. Personalized regimens remain pivotal in enhancing therapeutic efficacy and long-term disease control. Current review advocates for a shift toward precision medicine, highlighting the critical need for interdisciplinary collaboration to bridge molecular discoveries with clinical innovations. Ultimately, these advancements promise to revolutionize the management of chronic HBV, paving the way for potential cures and improved patient outcomes.

Role of Rifaximin in the Prognosis of Critically Ill Patients with Liver Cirrhosis

Background/Objectives: Critically ill patients with liver cirrhosis impose a substantial health burden on the world. Rifaximin is a potential treatment option for such patients. Methods: We extracted critically ill patients with liver cirrhosis from the Medical Information Mart for Intensive Care (MIMIC) IV database. Based on study outcomes, the current study included prevention and treatment cohorts. A 1:1 propensity score matching (PSM) analysis was performed to match the characteristics of patients. The risk of ICU admission and intensive care unit (ICU), in-hospital, 90-day, and 180-day death were explored. Cox regression analyses were conducted, and hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated. Kaplan-Meier curves were further drawn to demonstrate the cumulative 90-day and 180-day survival rate. Results: Overall, 5381 critically ill patients with liver cirrhosis were included. In the prevention cohort, rifaximin could decrease the risk of ICU admission (HR = 0.427, 95%CI: 0.338-0.539, p < 0.001). In the treatment cohort, rifaximin could decrease the risk of ICU (HR = 0.530, 95%CI: 0.311-0.902, p = 0.019) and in-hospital death (HR = 0.119, 95%CI: 0.033-0.429, p = 0.001) in critically ill patients with liver cirrhosis. However, rifaximin could not decrease the risk of 90-day (HR = 0.905, 95%CI: 0.658-1.245, p = 0.541) and 180-day (HR = 1.043, 95%CI: 0.804-1.353, p = 0.751) death in critically ill patients with liver cirrhosis. Kaplan-Meier curve analyses also showed that rifaximin could not significantly decrease the 90-day (p = 0.570) and 180-day (p = 0.800) cumulative mortality. Conclusions: This study suggests that rifaximin can significantly decrease the risk of ICU admission and improve short-term survival but does not impact long-term survival in critically ill patients with liver cirrhosis.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the “APASL ACLF Research Consortium (AARC)” was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia–Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the ‘Golden Therapeutic Window’, the ‘transplant window’, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The ‘Kyoto APASL Consensus’ presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Towards evidence-based empiric antibiotic recommendations for spontaneous infections in patients with cirrhosis

BACKGROUND

With the emergence of multidrug-resistant infections, healthcare professionals must evaluate the effectiveness of empiric antibiotic treatments.

AIMS

To assess the antibiotic susceptibility patterns of microorganisms causing spontaneous infections in patients with cirrhosis and to evaluate the suitability of empiric antibiotic treatments based on major clinical guidelines.

METHODS

This cross-sectional study utilized two datasets from prospective studies of patients with cirrhosis and culture-positive spontaneous bacterial infections in Argentina and Uruguay. We estimated susceptibility to commonly used antibiotics and assessed coverage following European and American recommendations.

RESULTS

We analyzed 238 episodes of culture-positive spontaneous infections in 229 patients. When implementing the recommendations for empiric treatment of community-acquired spontaneous infections, ceftazidime would result in 39 % coverage, whereas ceftriaxone would reach 70 %. Cefepime, which is not included in the recommendations, would have provided coverage of 74 %. Using ertapenem for nosocomial infections would have only covered 56 % of these episodes, whereas meropenem or imipenem reached 73 % coverage. Only the combination of meropenem or imipenem plus vancomycin would achieve a coverage surpassing 85 % in healthcare-associated or nosocomial spontaneous bacterial infections.

CONCLUSIONS

Our study uncovers inadequate coverage in specific clinical scenarios when adhering to recommendations, underscoring the necessity of guidelines based on local epidemiological data.

Identification of multiple complications as independent risk factors associated with 1-, 3-, and 5-year mortality in hepatitis B-associated cirrhosis patients

BACKGROUND

Hepatitis B-associated cirrhosis (HBC) is associated with severe complications and adverse clinical outcomes. This study aimed to develop and validate a predictive model for the occurrence of multiple complications (three or more) in patients with HBC and to explore the effects of multiple complications on HBC prognosis.

METHODS

In this retrospective cohort study, data from 121 HBC patients treated at Nanjing Second Hospital from February 2009 to November 2019 were analysed. The maximum follow-up period was 10.75 years, with a median of 5.75 years. Eight machine learning techniques were employed to construct predictive models, including C5.0, linear discriminant analysis (LDA), least absolute shrinkage and selection operator (LASSO), k-nearest neighbour (KNN), gradient boosting decision tree (GBDT), support vector machine (SVM), generalised linear model (GLM) and naive Bayes (NB), utilising variables such as medical history, demographics, clinical signs, and laboratory test results. Model performance was evaluated via receiver operating characteristic (ROC) curve analysis, residual analysis, calibration curve analysis, and decision curve analysis (DCA). The influence of multiple complications on HBC survival time was assessed via Kaplan‒Meier curve analysis. Furthermore, LASSO and univariable and multivariable Cox regression analyses were conducted to identify independent prognostic factors for overall survival (OS) in patients with HBC, followed by ROC, C-index, calibration curve, and DCA curve analyses of the constructed prognostic nomogram model. This study utilized bootstrap resampling for internal validation and employed the Medical Information Mart for Intensive Care IV (MIMIC-IV) database for external validation.

RESULTS

The GBDT model exhibited the highest area under the curve (AUC) and emerged as the optimal model for predicting the occurrence of multiple complications. The key predictive factors included posthospitalisation fever (PHF), body mass index (BMI), retinol binding protein (RBP), total bilirubin (TB) levels, and eosinophils (EOS). Kaplan-Meier analysis revealed that patients with multiple complications had significantly worse OS than those with fewer complications. Additionally, multivariable Cox regression analysis, informed by least absolute shrinkage and LASSO selection, identified hepatocellular carcinoma (HCC), multiple complications, and lactate dehydrogenase (LDH) levels as independent prognostic factors for OS. The prognostic model demonstrated 1-year, 3-year, and 5-year OS ROC AUCs of 0.802, 0.793, and 0.817, respectively. For the internal validation cohort, the corresponding AUC values were 0.797, 0.832, and 0.835. In contrast, the external validation cohort yielded a 1-year ROC AUC of 0.707. Calibration curves indicated good consistency of the model, and DCA demonstrated the model's clinical utility, showing high net benefits within certain threshold ranges. Compared with the univariable models, the multivariable ROC curves indicated higher AUC values for this prognostic model, and the model also possessed the best c-index.

CONCLUSION

The GBDT prediction model provides a reliable tool for the early identification of high-risk HBC patients prone to developing multiple complications. The concurrent occurrence of multiple complications is an independent prognostic factor for OS in patients with HBC. The constructed prognostic model demonstrated remarkable predictive performance and clinical applicability, indicating its crucial role in enhancing patient outcomes through timely and targeted interventions.

Acute-on-chronic liver failure (ACLF): the 'Kyoto Consensus'-steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Spontaneous bacterial peritonitis and soft tissue healing after tooth extraction in liver cirrhosis patients

OBJECTIVE

The objective of this study was to identify the association between tooth extraction and occurrence of spontaneous bacterial peritonitis (SBP) and to assess delayed soft tissue healing of extraction sockets in patients with cirrhosis.

STUDY DESIGN

One hundred nineteen participants awaiting liver transplantation who required tooth extraction were included. Seven days before the surgery, the patients underwent panoramic radiography and laboratory examinations. Soft tissue healing was evaluated 7 days after the tooth extraction and medical records were checked after 21 days for development of SBP. The relationship between predictive factors and outcomes was assessed by using multiple binomial logistic regression.

RESULTS

One hundred ninety-five teeth were extracted, resulting in 146 alveolar wounds, in which the majority (47%) consisted of alveolar sockets of multirooted teeth. One participant was diagnosed with SBP (Escherichia coli [E. coli]) and another diagnosed with bacterascites (Streptococcus viridans [S. viridans] group), occurring 11 and 6 days after tooth extraction. Poor soft tissue healing was observed in 20 (13.7%) patients, which was correlated to 2 risk factors, that is, jaundice (P = .007, adjusted odds ratio [OR] = 4.91, 95% confidence interval [CI] = 1.56-15.47) and moderate neutropenia (P = .048, adjusted OR = 13.99, 95% CI = 1.02-192.07).

CONCLUSIONS

No association was found between tooth extraction and SBP in patients with cirrhosis. The delayed soft tissue healing was related to jaundice (hyperbilirubinemia) and moderate neutropenia.

Hepatic encephalopathy and spontaneous bacterial peritonitis are associated with increased liver-related readmissions in cirrhosis

Introduction

Liver disease remains a significant global health concern. In China, the number of patients with liver cirrhosis is estimated to reach 7 million. In addition to the high risk of death, cirrhosis leads to several severe complications. Patients with cirrhosis have significantly longer hospital stays and higher total hospital costs than those without cirrhosis. We aimed to investigate the predictors of readmission among patients with cirrhosis in China.

Materials and methods

We conducted a retrospective study to evaluate adult patients with cirrhosis. Data on various sociodemographic, clinical, and hospitalization characteristics were collected. We defined the primary endpoint as the first liver-related readmission occurring within 30-90 days of initial hospitalization. Adult patients with cirrhosis admitted to our hospital between January 2009 and December 2022 were included. Differences between groups were analyzed using Student's t-test and chi-square test. Logistic and multiple linear regression analyses were performed to identify predictors associated with readmission and the length of the first hospitalization.

Results

In total, 1,285 patients were diagnosed with cirrhosis. Among these patients, 767 (59.7%) were males, and the mean age was 58.9 ± 12.3 years. Seventy-two (5.6%) and 154 (12.0%) patients were readmitted within 30 and 90 days, respectively. Compared with those who were not readmitted, patients readmitted at 30-day and 90-day had a higher proportion of males, ascites, spontaneous bacterial peritonitis, electrolyte abnormalities, higher Child-Pugh-Turcotte scores, longer initial hospital stays, and higher initial hospitalization costs. Logistic regression analysis indicated that hepatic encephalopathy, spontaneous bacterial peritonitis, diabetes, and ascites were predictors of 30- and 90-day readmission. Hypertension and spontaneous bacterial peritonitis were significant predictors of the length of the first hospitalization.

Conclusion

Patients with cirrhosis presenting with hepatic encephalopathy, ascites, and spontaneous bacterial peritonitis may have a higher risk of rehospitalization.

Pathogens and Prognosis of Deep Neck Infection in Patients With Liver Cirrhosis

OBJECTIVE

This study aims to investigate the differences in pathogenic bacterial spectra between patients with deep neck infection (DNI) with and without liver cirrhosis (LC). The goal is to identify specific pathogens prevalent in LC-DNI to guide the selection of empiric antibiotics, improving treatment outcomes and prognosis.

STUDY DESIGN

This is a retrospective study.

METHODS

The Chang Gung Research Database (CGRD) is a deidentified medical database encompassing seven hospitals within Taiwan's largest medical system. We analyzed data from 2004 to 2018 on DNI patients hospitalized with or without LC, categorizing them into these two groups. This study primarily focused on comparing the bacterial culture results of these groups, alongside an analysis of their treatment modalities (medication alone or surgery) and prognostic outcomes.

RESULTS

From a total of 11,455 DNI patients identified in the CGRD, 76 LC-DNI patients and 11,178 non-LC-DNI patients met the inclusion criteria after exclusions. The LC group had significantly higher rates of surgical debridement (34.2% vs. 19.4%, p = 0.002), ICU admission (22.4% vs. 10.7%, p = 0.004), and mediastinal complications (7.9% vs. 2.1%, p = 0.005). Although the overall mortality rates were not significantly different between the two groups (6.6% vs. 4.6%, p = 0.401), the mediastinitis-related mortality rate was significantly higher in the LC-DNI group (2.6% vs. 0.2%, p = 0.015). Bacterial culture analysis revealed that LC-DNI patients predominantly presented with Klebsiella pneumoniae (KP) as the primary facultative anaerobic pathogen, whereas non-LC-DNI patients were most infected with Viridans streptococcus (VS). For anaerobic bacteria, both groups consistently cultured Peptostreptococcus micros and Prevotella intermedia as the predominant species.

CONCLUSIONS

LC-DNI patients are predominantly infected with KP, a Gram-negative bacillus, unlike the Gram-positive cocci, VS, in non-LC-DNI. Anaerobic pathogens were similar in both groups. Empiric antibiotics for LC-DNI should target KP and anaerobes to improve outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 2025.

Perioperative infections as a prognostic risk factor in hepatocellular carcinoma and cholangiocellular carcinoma: a comparative analysis

BACKGROUND

Hepatocellular Carcinoma (HCC) and cholangiocellular adenocarcinoma (CCA) are the most common primary liver tumors representing a major global health burden. In early disease stages, tumor resection may provide long-term survival in selected patients. However, morbidity and mortality rates are still relatively high after extended liver surgery with perioperative bacterial infections representing major complications. In this study, we evaluate the impact of perioperative infection on the postoperative overall survival (OS) of patients undergoing resection of HCC or CCA.

MATERIAL AND METHODS

Two hundred two patients that received liver surgery for HCC (139) or CCA (63) at our tertiary referral center were included between 2008 and 2020. Infection prior or after surgery was assessed using patient documentation and correlated to patients´ survival rates and other clinical characteristics.

RESULTS

Patients with perioperative infection displayed a significantly impaired OS compared to patients without a documented infection (419 (95% CI: 262-576) days vs. 959 (95% CI: 637-1281) days; log rank X2(1) = 10.28; p < 0.001). Subgroup analysis revealed that this effect was only observed among HCC patients, while the outcome of CCA patients was independent of pre- or postoperative infections. Moreover, non-anatomical resection of liver tumors was beneficial in patients with HCC (1541 (95%CI: 1110-1972) vs. 749 (95%CI: 0-1528) days; log rank X2(1) = 5.387; p = 0.02) but not CCA.

CONCLUSION

Perioperative infection is an important prognostic factor after surgery for HCC but not CCA.

Antibiotic prophylaxis to prevent infection in patients with Child-Pugh A cirrhosis with upper gastrointestinal bleed: an open label randomised controlled trial

BACKGROUND AND AIMS

Although beneficial in reducing the risk of bacterial infections in patients with advanced decompensated cirrhosis after upper gastrointestinal (GI) bleed, the utility of prophylactic antibiotics in those with Child-Pugh A cirrhosis is not known. We studied if prophylactic antibiotics can be withheld in this cohort.

METHODS

This was a single-centre, open-label randomised-controlled-trial with non-inferiority design. Patients of Child-Pugh A cirrhosis with upper-GI bleed and hemodynamic stability were randomised to receive either no prophylactic antibiotics (test-group) or ceftriaxone [standard of care (SOC)] for 72 h alongside standard medical management. The primary outcome was infection at day-5 in both arms. Secondary outcomes included failure to control bleed, mortality at day-5, and at 6 weeks.

RESULTS

Eligible patients (n = 180; mean age 45.1 ± 13.1 years, 76.9% males; median MELDNa 9 [interquartile-range: 7-12]) of predominant non-viral etiology (alcohol: 43.4%; non-alcoholic steatohepatitis: 21.7%) were randomised, of whom outcomes could be reliably assessed for 172 and 140 patients at 5-day and 6-week follow-up, respectively. Rate of day-5 infections in test-group [7.0% (95% CI 2.8-15.1%)] was non-inferior to SOC arm [11.6% (95% CI 6.02-20.8%); absolute risk difference: -4.7% (95% CI -13.3% to 4.0%; non-inferior at 10% margin)]. Spontaneous bacterial peritonitis following post-bleed ascites was the most common site of infection in both groups (10/16; 66.7%). Rates of failure to control bleed [0% vs 4.9; absolute-risk-difference: -4.6% (95% CI -9.1% to 0.2%)], day-5 mortality [0% vs 2.5%; absolute-risk-difference: -2.3% (-5.5% to 0.9%)], and 6-week mortality [1.4% vs 2.5%; absolute-risk-difference: -1.6% (-6.5% to 3.2%)] were comparable in both arms.

CONCLUSION

Among patients with Child-Pugh A cirrhosis with hemodynamic stability, withholding prophylactic antibiotics after upper GI bleed was not associated with increased risk of post-bleed infections.

HLA evolutionary divergence effect on bacterial infection risk in cirrhotic liver transplant candidates

Bacterial infections are common in cirrhosis patients, increasing the risk of decompensation and death. The impact of HLA evolutionary divergence (HED) on infection risk hasn't been studied in humans before. We conducted a retrospective study on cirrhosis patients awaiting liver transplantation (LT) from January 2019 to February 2022, examining class I and II-HED effects on bacterial infections and cirrhosis decompensation. We included 269 cirrhosis patients. Among them, 98 experienced 153 bacterial infections. Multivariable analysis after variable selection revealed that higher class II-HED was linked to fewer bacterial infections (p = 0.034), while class I-HED showed no effect (p = 0.074). Independent risk factors for bacterial infections included invasive procedures (p < 0.001), ICU hospitalization (p < 0.001), recent antibiotic treatment (p = 0.046), rifaximin use (p = 0.043), and cirrhosis decompensation (p = 0.002). Neither class I nor II-HED affected decompensation risk. This pioneering study shows that high class II-HED levels may protect against bacterial infections in cirrhosis patients awaiting LT, suggesting an immunological mechanism at play.

Antibiotics in decompensated liver disease - who, when and for how long?

INTRODUCTION

Bacterial infections are a leading cause of hospitalization and mortality in patients with decompensated cirrhosis. Antibiotic prophylaxis in cirrhotic patients has demonstrated significant short-term reductions in bacterial infections in randomized controlled trials, but at the cost of drug resistance and with uncertain survival benefits.

AREAS COVERED

This review examines antibiotic use in cirrhosis, focusing on patients most likely to benefit from antibiotic prophylaxis, management strategies for infections through risk-based antibiotic selection and timely treatment initiation, challenges posed by the emergence of multidrug-resistant organisms, and principles of antimicrobial stewardship.

EXPERT OPINION

The efficacy of prophylaxis has decreased over time, and current registry data have questioned its use, emphasizing the need for better risk-based individualized strategies. When bacterial infections occur, the efficacy of antimicrobial therapies depends heavily on local epidemiological patterns and individual patient risk factors, necessitating tailored antibiotic selection based on regional resistance data and specific clinical scenarios. Nosocomial infections, colonization with multidrug-resistant organisms, and prior exposure to systemic antibiotics are key risk factors that should guide empirical therapy selection. Until evidence-based algorithms are available, clinicians should continue to adopt individualized approaches, guided by available evidence, local specificities, and antimicrobial stewardship principles to optimize patient outcomes.

Bacterial infection adversely increases the risk of decompensation in patients with hepatitis B virus-related compensated cirrhosis: a retrospective study

BACKGROUND

Hepatitis B virus related compensated cirrhosis generally has a favorable prognosis until decompensation occurs. Bacterial infections are prevalent in Hepatitis B virus related decompensated cirrhosis.Bacterial infection and decompensated hepatitis B cirrhosis are mutually reinforcing. And it also interacts with and promotes certain decompensation-related events. However, the impact of bacterial infections on the progression from compensated to decompensated cirrhosis in Hepatitis B patients remains unclear.

METHODS

We retrospectively analyzed the baseline characteristics of 1,011 patients with Hepatitis B virus related compensated cirrhosis. Using time-dependent regression analysis, we evaluated whether bacterial infections increase the risk of decompensation, defined as the occurrence of ascites, hepatic encephalopathy, or variceal bleeding.

RESULTS

A total of 1,011 patients were retrospectively analyzed over a median follow-up period of 79 months. Bacterial infections were observed in 89 patients (8.8%). Respiratory and urinary tract infections were the most common bacterial infections.Decompensation occurred in 44.9% of patients with bacterial infections, compared to 9% of those without BIs. Patients with bacterial infections had a higher risk of decompensation ([OR] 1.024; 95% CI 1.016-1.032; p < 0.001) than those without bacterial infections.

CONCLUSION

Our findings suggest that bacterial infections have a significant impact on the progression of hepatitis B virus related compensated cirrhosis, notably increasing the risk of decompensation.

Modulation of brain energy metabolism in hepatic encephalopathy: impact of glucose metabolic dysfunction

Cerebral function is linked to a high level of metabolic activity and relies on glucose as its primary energy source. Glucose aids in the maintenance of physiological brain activities; as a result, a disruption in metabolism has a significant impact on brain function, launching a chain of events that leads to neuronal death. This metabolic insufficiency has been observed in a variety of brain diseases and neuroexcitotoxicity disorders, including hepatic encephalopathy. It is a significant neurological complication that develops in people with liver disease, ranging from asymptomatic abnormalities to coma. Hyperammonemia is the main neurotoxic villain in the development of hepatic encephalopathy and induces a wide range of complications in the brain. The neurotoxic effects of ammonia on brain function are thought to be mediated by impaired glucose metabolism. Accordingly, in this review, we provide an understanding of deranged brain energy metabolism, emphasizing the role of glucose metabolic dysfunction in the pathogenesis of hepatic encephalopathy. We also highlighted the differential metabolic profiles of brain cells and the status of metabolic cooperation between them. The major metabolic pathways that have been explored are glycolysis, glycogen metabolism, lactate metabolism, the pentose phosphate pathway, and the Krebs cycle. Furthermore, the lack of efficacy in current hepatic encephalopathy treatment methods highlights the need to investigate potential therapeutic targets for hepatic encephalopathy, with regulating deficient bioenergetics being a viable alternative in this case. This review also demonstrates the importance of the development of glucose metabolism-focused disease diagnostics and treatments, which are now being pursued for many ailments.

Non-invasive tests for alcohol-associated liver disease

Alcohol consumption is a global phenomenon and a major contributor to alcohol-associated liver disease (ALD). Detecting individuals at risk of ALD has been challenging, with only a small fraction of patients being identified at early stages compared to other chronic liver diseases. In response to this challenge, non-invasive tests (NITs) have become essential tools for the detection of ALD, offering opportunities for early identification and intervention to mitigate the disease burden. Noninvasive alcohol consumption biomarkers are crucial in estimating individuals' recent alcohol intake, providing valuable insights into their drinking patterns. Various NITs have been investigated for the initial screening of asymptomatic individuals at risk of ALD, as well as for identifying specific stages of the disease. These NITs are applied in 2 main clinical scenarios: population-based stratification for identifying and predicting liver-related symptoms and diagnosing and prognosticating compensated cirrhosis or advanced chronic liver disease in secondary or tertiary care settings. Moreover, NITs play a significant role in the prognostic assessment of patients with various manifestations of ALD, including alcohol-associated hepatitis (AH), decompensated cirrhosis, and metabolic-associated and ALD. These tests guide appropriate treatment decisions and predict outcomes. In this review, various NITs for the early detection and monitoring of alcohol consumption were discussed. Additionally, the evaluation of NITs for screening and predicting ALD and liver complications was addressed comprehensively. Future perspectives of NITs for ALD were explored, alongside a thorough discussion of the opportunities and challenges associated with NITs for ALD screening.

Construction of a prediction model for hepatic encephalopathy in acute-on-chronic liver failure patients

OBJECTIVE

Hepatic encephalopathy (HE) is a serious complication of acute-on-chronic liver failure (ACLF) that requires early detection and intervention to positively impact patient prognosis. This study aimed to develop a reliable model to predict HE in ACLF patients during hospitalization.

METHODS

Retrospectively recruiting 255 hepatitis B-related ACLF patients, including 67 who developed HE during hospitalization, the study analysed clinical data and biochemical indices collected during the first week of admission. The least absolute shrinkage and selection operator (LASSO) was used to identify characteristic predictors for hospitalization HE events, and a logistic regression model was subsequently developed. Receiver operating characteristic (ROC) curves, calibration curves, and bootstrap resampling were used to evaluate the model's discrimination, consistency, and accuracy, and a nomogram was created to visualize the model. An external validation cohort of 236 liver failure patients collected from the same medical centre between 2007 and 2010 was used to validate the model.

RESULTS

The study found that blood urea nitrogen (BUN), alpha-fetoprotein (AFP), international normalized ratio (INR), serum ammonia, and infection complications during hospitalization were risk factors for HE in ACLF patients. The new model predicted the development of HE in ACLF patients with an area under the receiver operating characteristic curve (AUROC) of 85.2%, which was superior to other models. The best threshold for the new model was 0.28, resulting in a specificity of 81.4% and a sensitivity of 80.6%. In the validation group, the new model showed similar results, with an AUROC of 79% and a specificity of 83.6% and a sensitivity of 56.6%.

CONCLUSION

This study developed and validated a new prediction model for HE in ACLF patients offering a useful tool for early identification of patients with a high risk of HE in clinical settings. However, to ascertain the model's general effectiveness, future prospective multicentre studies are warranted.

Sensitivity of diagnosis of spontaneous bacterial peritonitis is higher with the automated cell count method

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is one of the most important complications of patients with liver cirrhosis entailing high morbidity and mortality. Making an accurate early diagnosis of this infection is key in the outcome of these patients. The current definition of SBP is based on studies performed more than 40 years ago using a manual technique to count the number of polymorphs in ascitic fluid (AF). There is a lack of data comparing the traditional cell count method with a current automated cell counter. Moreover, current international guidelines do not mention the type of cell count method to be employed and around half of the centers still rely on the traditional manual method.

AIM

To compare the accuracy of polymorph count on AF to diagnose SBP between the traditional manual cell count method and a modern automated cell counter against SBP cases fulfilling gold standard criteria: Positive AF culture and signs/symptoms of peritonitis.

METHODS

Retrospective analysis including two cohorts: Cross-sectional (cohort 1) and case-control (cohort 2), of patients with decompensated cirrhosis and ascites. Both cell count methods were conducted simultaneously. Positive SBP cases had a pathogenic bacteria isolated on AF and signs/symptoms of peritonitis.

RESULTS

A total of 137 cases with 5 positive-SBP, and 85 cases with 33 positive-SBP were included in cohort 1 and 2, respectively. Positive-SBP cases had worse liver function in both cohorts. The automated method showed higher sensitivity than the manual cell count: 80% vs 52%, P = 0.02, in cohort 2. Both methods showed very good specificity (> 95%). The best cutoff using the automated cell counter was polymorph ≥ 0.2 cells × 109/L (equivalent to 200 cells/mm3) in AF as it has the higher sensitivity keeping a good specificity.

CONCLUSION

The automated cell count method should be preferred over the manual method to diagnose SBP because of its higher sensitivity. SBP definition, using the automated method, as polymorph cell count ≥ 0.2 cells × 109/L in AF would need to be considered in patients admitted with decompensated cirrhosis.

A comprehensive review of diagnosis and management of alcohol-associated hepatitis

Alcohol-associated hepatitis is an extreme form of alcohol-related liver disease associated with high short-term mortality. Currently, there are no authorized therapies for the treatment of severe alcohol-associated hepatitis. Important diagnostic steps for alcohol-associated hepatitis include recognizing the presence of an alcohol use disorder, distinguishing alcohol-related liver disease from metabolic-dysfunction-associated steatotic liver disease, ruling out alternative causes of acute hepatitis, confirming the diagnosis with validated criteria or a liver biopsy, and using the model for end-stage liver disease score to predict clinical outcome and initiate therapy. Due to the lack of other effective therapy options, corticosteroids continue to be used as initial treatment for patients with severe alcohol-associated hepatitis. Patients who do not improve while on steroid treatment and are ideal candidates should be considered for curative liver transplantation as soon as possible. Avoiding unnecessary and ineffective pharmacological and interventional therapy can help to keep costs down. If a patient is not a good candidate for a transplant or is rapidly deteriorating in health due to a condition such as acute or chronic liver failure, a salvage/bridge to transplant should be pursued through enrolment in a clinical trial program. The role of healthy donor stool transplant and targeted bacteriophage therapy seems promising, pending prospective controlled trials.

Spontaneous bacterial peritonitis recurrence on norfloxacin secondary prophylaxis

BACKGROUND AND STUDY AIMS

Secondary prophylaxis with norfloxacin reduces recurrence of spontaneous bacterial peritonitis (SBP) significantly. No data available from Asia-Pacific region about recurrence of SBP in these patients.

PATIENTS AND METHODS

In a retrospective cohort study, we assessed recurrence rate of SBP in patients on norfloxacin secondary prophylaxis. One year recurrence of SBP, its profile, response rate and risk factors for recurrence were assessed.

RESULTS

A total of 112 patients were analysed. During first episode of SBP, culture positive rate was 39/112(34.8 %) and resistance to ceftriaxone was 51.2 %. Overall efficacy of ceftriaxone as first line antibiotic was 70.5 % (70/112), but only 49 % (19/39) among culture positive patients. E. coli is the commonest organism isolated (21/39, 53.8 %), MDR organism in 12.8 % (5/39). Cumulative incidence of SPB recurrence was 22.3 % (25/112) on norfloxacin secondary prophylaxis at 1 year. Culture positive rate in recurrent SBP was 48 % (12/25) and ceftriaxone resistance and MDR organism were seen in 66.6 % and 16.6 %. Overall response rate to ceftriaxone in recurrent SBP was 40 % (10/25) and 21 % (3/14) in culture positive patients. Risk factors for SBP recurrence were age, INR and albumin (p < 0.05). No increase cumulative incidence of death among patients with or without recurrence.

CONCLUSION

Despite recent changes in bacteriological profile in SBP, recurrence of SBP on norfloxacin prophylaxis remains low. In recurrent SBP, response to ceftriaxone is significantly lower than first episode and there is trend towards increase in MDR organism in culture positive patient receiving norfloxacin.

Diagnostic model for spontaneous bacterial peritonitis in cirrhotic patients with ascites: a multicenter cohort study

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a potentially life-threatening complication of cirrhotic ascites. Early diagnosis and treatment of SBP are essential to improve the survival rates and prognosis of patients. We aimed to identify the predictors of SBP to establish a new noninvasive early diagnostic tool.

METHODS

We screened 1618 patients who underwent paracentesis due to cirrhotic ascites between January 2017 and December 2018 in three hospitals. We evaluated the symptomatic, clinical, and laboratory parameters to identify the predictors of SBP. The primary diagnostic model was displayed as a nomogram.

RESULTS

The model included abdominal pain, diarrhea, white blood cell count, neutrophil percentage, procalcitonin, C-reactive protein, lactate dehydrogenase, glucose, and Model for End-stage Liver Disease score. The model's diagnostic performance was good, with an AUC of 0.84 [95% confidence interval (CI), 0.81-0.87] in the training cohort. In the validation cohort, the diagnostic ability was also good, with AUCs of 0.87 (95% CI, 0.83-0.91) and 0.90 (95% CI, 0.87-0.94) for inner and outer validation queues, respectively. Moreover, the decision curve analysis confirmed the clinical utility of the nomogram model. In addition, we developed a Microsoft Excel calculation model to allow convenient adoption of the model in clinical practice.

CONCLUSION

We developed good performing diagnostic models for SBP.

Biomarker for infection in children with decompensated chronic liver disease: Neutrophilic CD64 or procalcitonin?

OBJECTIVE

Biomarkers with high accuracy for identification of infection in decompensated chronic liver disease (DCLD) are urgently needed. We compared the accuracy of neutrophilic cluster of differentiation 64 (nCD64) with procalcitonin for diagnosis of bacterial infection in children with DCLD.

METHODS

Consecutive children admitted with DCLD were enrolled prospectively. nCD64 was assessed by flow cytometry and expressed in percentage. nCD64, procalcitonin and hemogram were measured at admission and 7-14 days after treatment in those with infection. Complete work-up for infection was done. Presence, site and severity of infection was classified as per guidelines.

RESULTS

107 children [64 boys, age 97(18-168) months] were enrolled. 78(72.9%) had infection, 26(24%) had severe sepsis and 60(56%) had systemic inflammatory response syndrome. The commonest site of infection was ascitic fluid (n=37), followed by pneumonia (n=24), urinary tract (n=15), bacteraemia (n=10), cholangitis (n=8) and cellulitis (n=3). nCD64 (cut-off-51%, AUC-0.82) had a higher sensitivity (79.5%) and specificity (82.8%) than procalcitonin (cut-off ≥0.58ng/mL, AUC-0.74, sensitivity-76.9% and specificity-62.1%) for diagnosis of infection. nCD64 and procalcitonin correlated with infection severity, being highest in children with severe sepsis [88(71-97) %and 1.98(0.83-10.36) ng/mL], than in infection alone [72(45-84) % and 1.09(0.45-2.07) ng/mL], and no-infection [36(20.2-48) % and 0.42(0.19-1.08) ng/mL]. There was no difference in diagnostic utility of procalcitonin or nCD64 with different sites of infection. Elevation of all 3 parameters (nCD64, PCT and total leukocyte count) was uncommon but highly specific for presence of infection.

CONCLUSION

nCD64 identifies infection better than procalcitonin and correlates well with infection severity in children with DCLD.

Therapeutic potential of rifaximin in liver diseases

Rifaximin, derived from rifamycin, is a broad-spectrum antibiotic by inhibiting bacterial RNA synthesis. Rifaximin has a very low intestinal absorption and exerts its antimicrobial activity primarily in the intestinal tract. It regulates the gut microbiota with limited side effects systemically. Rifaximin has been recommended for the treatment of hepatic encephalopathy but some studies shed light on its medicinal effects in many other diseases. For instance, rifaximin may suppress the progression of liver fibrosis and its related complications, and ameliorate metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease, etc. Rifaximin can also mediate anti-inflammation, antiproliferation, and proapoptotic events by activating pregnane X receptor, which is efficious in cancers such as colon cancer. In addition, some investigations have shown rifaximin may play a therapeutic role in various autoimmune and neurological disorders. However, these findings still need more real-world practices and in-depth investigations to obtain more precise indications and fully elucidate the multifaceted potentials of rifaximin.

[When should a liver disease patient be admitted to the intensive care unit?]

Liver diseases are a significant global cause of morbidity and mortality. Liver cirrhosis can result in severe complications such as bleeding, hepatic encephalopathy (HE), and infections. Implementing a clear strategy for intensive care unit (ICU) admission management improves patient outcomes. Hemodynamically significant esophageal/gastric variceal bleeding (E/GVB) and grade 4 HE, when accompanied by the need for renal replacement therapy (RRT), are definitive indications for ICU admission. E/GVB, spontaneous bacterial peritonitis (SBP), and infections with multidrug-resistant organisms (MDRO) require close and stringent critical assessment. Patients with severe hepatorenal syndrome (HRS) or respiratory failure have increased baseline mortality and most likely benefit from early ICU treatment. Rapid identification of sepsis in patients with liver cirrhosis is a crucial criterion for ICU admission. Prioritizing cases based on mortality risk and clinical urgency enables efficient resource utilization and optimizes patient management. In addition, "Liver Units" provide an intermediate care (IMC) level for patients with liver diseases who require close monitoring but do not need immediate intensive care.

Efficacy of albumin use in decompensated cirrhosis and real-world adoption in Australia

The current treatment approach to patients with liver cirrhosis relies on the individual management of complications. Consequently, there is an unmet need for an overall therapeutic strategy for primary and secondary prevention of complications. The clinical potential of long-term albumin infusions supported by recent clinical trials has expanded its indications and holds promise to transform the management and secondary prevention of cirrhosis-related complications. This renewed interest in albumin comes with inherent controversies, compounding challenges and pressing need for rigorous evaluation of its clinical potential to capitalize on its therapeutic breakthroughs. Australia is among a few countries worldwide to adopt outpatient human albumin infusion. Here, we summarize currently available evidence of the potential benefits of human albumin for the management of multiple liver cirrhosis-related complications and discuss key challenges for wide application of long-term albumin administration strategy in Australian clinical practice. Australian Gastroenterological week (AGW), organised by the Gastroenterological Society of Australia (GESA), was held between 9-11 September 2022. A panel of hepatologists, advanced liver nurses and one haematologist, were invited to a roundtable meeting to discuss the use of long-term albumin infusions for liver cirrhosis. management in Australia. In this review, we summarise the proceedings of this meeting in context of the current literature.

Acute liver failure

Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.

Microbe-material hybrids for therapeutic applications

As natural living substances, microorganisms have emerged as useful resources in medicine for creating microbe-material hybrids ranging from nano to macro dimensions. The engineering of microbe-involved nanomedicine capitalizes on the distinctive physiological attributes of microbes, particularly their intrinsic "living" properties such as hypoxia tendency and oxygen production capabilities. Exploiting these remarkable characteristics in combination with other functional materials or molecules enables synergistic enhancements that hold tremendous promise for improved drug delivery, site-specific therapy, and enhanced monitoring of treatment outcomes, presenting substantial opportunities for amplifying the efficacy of disease treatments. This comprehensive review outlines the microorganisms and microbial derivatives used in biomedicine and their specific advantages for therapeutic application. In addition, we delineate the fundamental strategies and mechanisms employed for constructing microbe-material hybrids. The diverse biomedical applications of the constructed microbe-material hybrids, encompassing bioimaging, anti-tumor, anti-bacteria, anti-inflammation and other diseases therapy are exhaustively illustrated. We also discuss the current challenges and prospects associated with the clinical translation of microbe-material hybrid platforms. Therefore, the unique versatility and potential exhibited by microbe-material hybrids position them as promising candidates for the development of next-generation nanomedicine and biomaterials with unique theranostic properties and functionalities.

Infectious Complications of Portal Hypertension

Patients with cirrhosis and clinically significant portal hypertension are at high risk of developing bacterial infections (BIs) that are the most common trigger of acute decompensation and acute-on-chronic liver failure. Furthermore, after decompensation, the risk of developing BIs further increases in an ominous vicious circle. BIs may be subtle, and they should be ruled out in all patients at admission and in case of deterioration. Timely administration of adequate empirical antibiotics is the cornerstone of treatment. Herein, we reviewed current evidences about pathogenesis, clinical implications and management of BIs in patients with cirrhosis and portal hypertension.

Infections in cirrhosis

Cirrhosis is an immune dysfunction state, and as such, patients with cirrhosis are susceptible to bacterial, fungal, and viral infections. Because of infection, these patients have a propensity to develop multiorgan failure, which is associated with high mortality. Bacterial infections are the most prevalent type of infection in patients with cirrhosis, with the prevalence of bacterial infections in patients admitted for an acute decompensating event ranging from 24% to 29%. Together with invasive fungal infections, bacterial infections are the most severe. Multidrug-resistant organisms have been evolving at a rapid and alarming rate around the world, which presents enormous challenges. The development of effective measures for the prevention, early detection, and treatment of infections in patients with cirrhosis is challenging, given the rising incidence of infections in this patient population.

The value of presepsin and procalcitonin as prognostic factors for mortality in patients with alcoholic liver cirrhosis and acute on chronic liver failure

Background: Acute on chronic liver failure (ACLF) is typically characterized by a rapid progression of liver failure in patients with liver cirrhosis and it is triggered by a precipitant factor, usually a bacterial infection (BI). Considering the low accuracy of the inflammation biomarkers in liver cirrhosis, presepsin and procalcitonin have demonstrated a good diagnostic performance for BI. Understanding the key prognostic factors that influence patient outcomes can significantly impact clinical decision-making and improve patient care in ACLF which can lead to lower mortality rates. Aim: To evaluate the prognostic factors associated with 30-day mortality in patients with alcohol-related liver cirrhosis and ACLF. Methods: This retrospective study on 227 patients diagnosed with ACLF and alcohol-related liver cirrhosis analyzed the prognostic role of presepsin and procalcitonin serum levels. Results: The survival analysis according to the grade of ACLF showed that more than 80% of patients with ACLF grade 1 survived after 30 days, with a mean estimated time of death of 29 ±0.44 days (95 % CI: 28.17-29.92) compared to ACLF grade 2 (24.9±1.064 days; 95 % CI: 22.82-26.99) and ACLF grade 3 (21.05±1.17 days; 95 % CI: 18.75-23.34), with a mean overall survival on entire cohort of 25.69±0.52 days (95 % CI: 24.65-26.73). Presepsin (OR: 4.008, CI 95:3.130-6.456, p=0.001) and procalcitonin (OR: 3.666, CI 95:2.312-5.813, p=0.001) were the most significant factors associated with 30-day mortality. In ACLF grade 2, presepsin provides a better prediction of mortality at the cutoff value of 1050 pg/mL (Sensitivity 72%, Specificity 69%) than procalcitonin (AUC=0.727 95% CI 0.594-0.860, p<0.002) whereas in ACLF grade 3, a cutoff of 1450 pg/mL (Sensitivity 89%, Specificity 91%) presepsin had a more significant accuracy of mortality prediction (AUC=0.93 95% CI 0.81-0.99, p<0.001) than procalcitonin (AUC=0.731 95% CI 0.655-0.807, p<0.001). Conclusion: ACLF is associated with a high mortality rate and the risk of death increases with the grade of ACLF. Presepsin and procalcitonin serum levels are good prognostic factors for 30-day mortality and should be used in clinical practice to stratify the risk and provide and early and efficient treatment in patients with ACLF.

Outcome of dogs diagnosed with concurrent intrahepatic portosystemic shunts and vertebral lesions: six cases (2016-2022)

OBJECTIVES

To describe the clinical outcome of dogs diagnosed with concurrent discospondylitis/vertebral physitis and congenital intrahepatic portosystemic shunts.

MATERIALS AND METHODS

Medical records from two academic institutions were searched for dogs diagnosed with discospondylitis and/or vertebral physitis, and a concurrent intrahepatic portosystemic shunt. Dogs were excluded if they did not undergo attenuation of their shunt, did not have a single congenital intrahepatic shunt and did not have at least 90 days of follow-up.

RESULTS

Six dogs met the inclusion criteria and were included in the study. Discospondylitis alone was diagnosed in four dogs, vertebral physitis alone in one dog and both discospondylitis and vertebral physitis in one dog. Three dogs had a right divisional intrahepatic portosystemic shunt, and three dogs had a left divisional intrahepatic portosystemic shunt. Median duration of antimicrobial therapy was 112 days (range 14 to 240 days). Clinical resolution of discospondylitis and vertebral physitis was noted in all dogs. Endovascular attenuation was performed in all dogs a median of 82 days after presentation (range 1 to 317 days). No perioperative or postoperative complications occurred. All dogs were alive at the last available follow-up a median of 513 days after presentation (range 224 to 1504 days) and free of clinical signs associated with discospondylitis or vertebral physitis, as well as their portosystemic shunt.

CLINICAL SIGNIFICANCE

Dogs with intrahepatic portosystemic shunts may concurrently develop discospondylitis and vertebral physitis. With antimicrobial therapy and endovascular embolisation of their portosystemic shunt, all dogs in this study had a good outcome with clinical resolution of both disease processes. However, long-term follow-up was not obtained in all cases.

Limitations of current techniques in clinical antimicrobial resistance diagnosis: examples and future prospects

Antimicrobial resistance is a global threat to public health. Without proactive intervention, common infections may become untreatable, restricting the types of clinical intervention that can be undertaken and reversing improvements in mortality rates. Effective antimicrobial stewardship represents one approach to restrict the spread of antimicrobial resistance but relies on rapid and accurate diagnostics that minimise the unnecessary use of antibiotics. This is increasingly a key unmet clinical need. In this paper, we describe existing techniques for the detection of antimicrobial resistance, while examining their drawbacks and limitations. We also discuss emerging diagnostic technologies in the field, and the need for standardisation to allow for swifter and more widespread clinical adoption.

Clinical, experimental and pathophysiological effects of Yaq-001: a non-absorbable, gut-restricted adsorbent in models and patients with cirrhosis

OBJECTIVE

Targeting bacterial translocation in cirrhosis is limited to antibiotics with risk of antimicrobial resistance. This study explored the therapeutic potential of a non-absorbable, gut-restricted, engineered carbon bead adsorbent, Yaq-001 in models of cirrhosis and acute-on-chronic liver failure (ACLF) and, its safety and tolerability in a clinical trial in cirrhosis.

DESIGN

Performance of Yaq-001 was evaluated in vitro. Two-rat models of cirrhosis and ACLF, (4 weeks, bile duct ligation with or without lipopolysaccharide), receiving Yaq-001 for 2 weeks; and two-mouse models of cirrhosis (6-week and 12-week carbon tetrachloride (CCl4)) receiving Yaq-001 for 6 weeks were studied. Organ and immune function, gut permeability, transcriptomics, microbiome composition and metabolomics were analysed. The effect of faecal water on gut permeability from animal models was evaluated on intestinal organoids. A multicentre, double-blind, randomised, placebo-controlled clinical trial in 28 patients with cirrhosis, administered 4 gr/day Yaq-001 for 3 months was performed.

RESULTS

Yaq-001 exhibited rapid adsorption kinetics for endotoxin. In vivo, Yaq-001 reduced liver injury, progression of fibrosis, portal hypertension, renal dysfunction and mortality of ACLF animals significantly. Significant impact on severity of endotoxaemia, hyperammonaemia, liver cell death, systemic inflammation and organ transcriptomics with variable modulation of inflammation, cell death and senescence in the liver, kidneys, brain and colon was observed. Yaq-001 reduced gut permeability in the organoids and impacted positively on the microbiome composition and metabolism. Yaq-001 regulated as a device met its primary endpoint of safety and tolerability in the clinical trial.

CONCLUSIONS

This study provides strong preclinical rationale and safety in patients with cirrhosis to allow clinical translation.

TRIAL REGISTRATION NUMBER

NCT03202498.

Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections

End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.

CXCR6+CD69+ CD8+ T cells in ascites are associated with disease severity in patients with cirrhosis

Background & Aims

Patients with advanced cirrhosis often develop hepatic decompensation, which is accompanied by systemic inflammation and may eventually lead to acute-on-chronic liver failure. One important cause of systemic hyperinflammation is a dysregulated overshooting immune response in ascites in the abdominal cavity. In this study, we analyzed the role of CD8+ T cells in the ascites immune compartment.

Methods

Peripheral blood and ascites fluid were collected from 50 patients with decompensated cirrhosis. Phenotype and functional responses of CD8+ T cells were analyzed, and obtained data were compared with each other as well as with healthy controls and patients with compensated cirrhosis.

Results

High-dimensional flow cytometry revealed that CD8+ T cells are abundant in the ascites of patients with cirrhosis and exhibit a chronically activated bystander phenotype with innate-like functions. Indeed, we identified distinct CXCR6+CD69+ clusters of late effector memory CD8+ T cells that were rarely found in blood and correlated with clinical parameters of disease severity. Moreover, this CD8+ T-cell population was hyperresponsive to innate cytokines and exhibited cytokine-mediated bystander activation. Interestingly, the Janus kinase (JAK) inhibitor tofacitinib was able to effectively block bystander-activated CXCR6+CD69+ CD8+ T cells and significantly suppress effector molecule production.

Conclusions

The results indicate that CXCR6+CD69+ CD8+ T cells in ascites are associated with disease severity and may contribute to inflammation in patients with decompensated cirrhosis, suggesting that targeted inhibition of this immune cell subset may be a viable therapeutic option.

Impact and Implications

Patients with advanced cirrhosis often develop hepatic decompensation, which is accompanied by systemic inflammation and eventually leads to acute-on-chronic liver failure. One important cause of systemic hyperinflammation is a dysregulated overshooting immune response in ascites in the abdominal cavity. In this study, we demonstrate that CXCR6+CD69+ CD8+ T cells are abundant in the ascites of patients with cirrhosis, exhibit a chronically activated bystander phenotype, and correlate with clinical parameters of disease severity. Moreover, we show that the Janus kinase (JAK) inhibitor tofacitinib can effectively block these bystander-activated CXCR6+CD69+ CD8+ T cells, suggesting that targeted inhibition of this immune cell subset may be a potential therapeutic strategy.

Clinical trial number

Prospective registry: INFEKTA (DRKS00010664).

Multidrug-resistant bacterial infections after liver transplantation: Prevalence, impact, and risk factors

BACKGROUND & AIMS

Infections by multidrug-resistant bacteria (MDRB) are an increasing healthcare problem worldwide. This study analyzes the incidence, burden, and risk factors associated with MDRB infections after liver transplant(ation) (LT).

METHODS

This retrospective, multicenter cohort study included adult patients who underwent LT between January 2017 and January 2020. Risk factors related to pre-LT disease, surgical procedure, and postoperative stay were analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of MDRB infections within the first 90 days after LT.

RESULTS

We included 1,045 LT procedures (960 patients) performed at nine centers across Spain. The mean age of our cohort was 56.8 ± 9.3 years; 75.4% (n = 782) were male. Alcohol-related liver disease was the most prevalent underlying etiology (43.2.%, n = 451). Bacterial infections occurred in 432 patients (41.3%) who presented with a total of 679 episodes of infection (respiratory infections, 19.3%; urinary tract infections, 18.5%; bacteremia, 13.2% and cholangitis 11%, among others). MDRB were isolated in 227 LT cases (21.7%) (348 episodes). Enterococcus faecium (22.1%), Escherichia coli (18.4%), and Pseudomonas aeruginosa (15.2%) were the most frequently isolated microorganisms. In multivariate analysis, previous intensive care unit admission (0-3 months before LT), previous MDRB infections (0-3 months before LT), and an increasing number of packed red blood cell units transfused during surgery were identified as independent predictors of MDRB infections. Mortality at 30, 90, 180, and 365 days was significantly higher in patients with MDRB isolates.

CONCLUSION

MDRB infections are highly prevalent after LT and have a significant impact on prognosis. Enterococcus faecium is the most frequently isolated multi-resistant microorganism. New pharmacological and surveillance strategies aimed at preventing MDRB infections after LT should be considered for patients with risk factors.

IMPACT AND IMPLICATIONS

Multidrug-resistant bacterial infections have a deep impact on morbidity and mortality after liver transplantation. Strategies aimed at improving prophylaxis, early identification, and empirical treatment are paramount. Our study unveiled the prevalence and main risk factors associated with these infections, and demonstrated that gram-positive bacteria, particularly Enterococcus faecium, are frequent in this clinical scenario. These findings provide valuable insights for the development of prophylactic and empirical antibiotic treatment protocols after liver transplantation.

Epidemiological Study of Pathogens in Spontaneous Bacterial Peritonitis in 2017-2024-A Preliminary Report of the University Hospital in South-Eastern Poland

Spontaneous Bacterial Peritonitis (SBP) is a serious complication and a common cause of death in patients with liver cirrhosis. Between January 2017 and March 2024, a retrospective study was conducted involving 302 patients (>18 years old) with ascites treated at a tertiary referral center in south-eastern Poland. Microbiological analysis of the ascitic fluids was performed in all patients. The presence of microorganisms was found in samples from 17 patients, and 21 pathogens were isolated, including 15 Gram-positive bacteria and 6 Gram-negative bacteria. Staphylococcus epidermidis, MRCNS (methicillin-resistant coagulase-negative staphylococci, resistant to all beta-lactam antibiotics: penicillins, penicillins with beta-lactamase inhibitor, cephalosporins and carbapenems) was the main pathogen detected (19.05%, 4/21), followed by Enterococcus faecalis (9.52%, 2/21), Enterococcus faecium (9.52%, 2/21), Staphylococcus haemolyticus, MRCNS (4.76%, 1/21), Streptococcus mitis (9.52%, 2/21), Streptococcus parasanguinis (9.52%, 2/21), Micrococcus luteus (4.76%, 1/21) and Bacillus spp. (4.76%, 1/21). The following Gram-negative bacteria were also found in the specimens examined: Escherichia coli, ESBL (extended-spectrum β-lactamase producing E. coli) (4.76%, 1/21), Escherichia coli (4.76%, 1/21), Pseudomonas aeruginosa (4.76%, 1/21), Klebsiella oxytoca (9.52%, 2/21) and Sphingomonas paucimobilis (4.76%, 1/21). Gram-positive bacteria caused nosocomial infections in nine patients with SBP, Gram-negative bacteria caused nosocomial infections in two patients. In six patients with SBP, community-acquired infections caused by Gram-negative bacteria were found in three cases, Gram-positive bacteria in two cases, and in one case, community-acquired infection was caused by mixed Gram-positive and Gram-negative. Bacteria isolated from patients with hospital-acquired SBP showed higher drug resistance than those found in patients with non-hospital SBP. Bacterial infections in cirrhotic patients with complications may be responsible for their deteriorating health. Prompt intervention is critical to reducing mortality.

Evaluation of mucosal-associated invariant T-cells as a potential biomarker to predict infection risk in liver cirrhosis

BACKGROUND AND AIMS

Infection is a serious complication in patients with cirrhosis. Mucosal-associated invariant T (MAIT) cells are involved in the immune defense against infections and known to be impaired in several chronic conditions, including cirrhosis. Here, we evaluated if MAIT cell levels in peripheral blood are associated with risk of bacterial infections in patients with cirrhosis.

METHODS

Patients with cirrhosis seen at the Karolinska University Hospital, Stockholm, Sweden, between 2016 and 2019 were included. Levels of MAIT cells in peripheral blood were determined using flow cytometry. Baseline and follow-up data after at least two years of follow-up were collected by chart review for the primary outcome (bacterial infection) and secondary outcomes (decompensation and death). Competing risk and Cox regression were performed.

RESULTS

We included 106 patients with cirrhosis. The median MAIT cells fraction in the circulation was 0.8% in cirrhosis compared to 6.1% in healthy controls. In contrast to our hypothesis, we found an association in the adjusted analysis between relatively preserved MAIT cell levels, and a slightly higher risk to develop bacterial infections (adjusted subdistribution hazard ratio (aSHR) 1.15 (95%CI = 1.01-1.31). However, MAIT cell levels were not associated with the risk of hepatic decompensation (aSHR 1.19 (95%CI = 0.91-1.56)) nor with death (adjusted hazard ratio 1.10 (95%CI = 0.97-1.22)).

CONCLUSIONS

Relatively preserved MAIT cell levels in blood of patients with cirrhosis were associated with a somewhat higher risk of bacterial infections. The clinical relevance of this might not be strong. MAIT cells might however be an interesting biomarker to explore in future studies.

Determinants of clinical response to empirical antibiotic treatment in patients with cirrhosis and bacterial and fungal infections-Results from the ICA "Global Study" (EABCIR-Global Study)

BACKGROUND

The administration of an appropriate empirical antibiotic treatment is essential in cirrhosis and severe bacterial infections. We aimed to investigate the predictors of clinical response of empirical antibiotic treatment in a prospective cohort of patients with cirrhosis and bacterial and fungal infections included in the International Club of Ascites "Global Study."

METHODS

Patients hospitalized with cirrhosis and bacterial/fungal infection were prospectively enrolled at 46 centers. Clinical response to antibiotic treatment was defined according to changes in markers of infection/inflammation, vital signs, improvement of organ failure, and results of cultures.

RESULTS

From October 2015 to September 2016, 1302 patients were included at 46 centers. A clinical response was achieved in only 61% of cases. Independent predictors of lack of clinical response to empirical treatment were C-reactive protein (OR = 1.16; 95% CI = 1.02-1.31), blood leukocyte count (OR = 1.39;95% CI = 1.09-1.77), serum albumin (OR = 0.70; 95% CI = 0.55-0.88), nosocomial infections (OR = 1.96; 95% CI = 1.20-2.38), pneumonia (OR = 1.75; 95% CI = 1.22-2.53), and ineffective treatment according to antibiotic susceptibility test (OR = 5.32; 95% CI = 3.47-8.57). Patients with a lack of clinical response to first-line antibiotic treatment had a significantly lower resolution rate of infections (55% vs. 96%; p < 0.001), a higher incidence of second infections (29% vs. 15%; p < 0.001), shock (35% vs. 7%; p < 0.001) and new organ failures (52% vs. 19 %; p < 0.001) than responders. Clinical response to empirical treatment was an independent predictor of 28-day survival ( subdistribution = 0.20; 95% CI = 0.14-0.27).

CONCLUSIONS

Four out of 10 patients with cirrhosis do not respond to the first-line antibiotic therapy, leading to lower resolution of infections and higher mortality. Broader-spectrum antibiotics and strategies targeting systemic inflammation may improve prognosis in patients with a high degree of inflammation, low serum albumin levels, and severe liver impairment.

Development of a nomogram for predicting in-hospital mortality in patients with liver cirrhosis and sepsis

In this study, we aimed to investigate the risk factors associated with in-hospital mortality in patients with cirrhosis and sepsis, establish and validate the nomogram. This retrospective study included patients diagnosed with liver cirrhosis and sepsis in the Medical Information Mart for Intensive Care IV (MIMIC-IV). Models were compared by the area under the curve (AUC), integrated discriminant improvement (IDI), net reclassification index (NRI) and decision curve analysis (DCA). A total of 1,696 patients with cirrhosis and sepsis were included in the final cohort. Our final model included the following 9 variables: age, heartrate, total bilirubin (TBIL), glucose, sodium, anion gap (AG), fungal infections, mechanical ventilation, and vasopressin. The nomogram were constructed based on these variables. The AUC values of the nomograms were 0.805 (95% CI 0.776-0.833), which provided significantly higher discrimination compared to that of SOFA score [0.684 (95% CI 0.647-0.720)], MELD-Na [0.672 (95% CI 0.636-0.709)] and ABIC [0.674(95% CI 0.638-0.710)]. We established the first nomogram for predicting in-hospital mortality in patients with liver cirrhosis and sepsis based on these factors. This nomogram can performs well and facilitates clinicians to identify people at high risk of in-hospital mortality.